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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web; www.sigov.orq/ehd PUMP INSPECTION CHECK LIST Address: Permit#: Ins ection D to -16 1 -0 2- lo:z Lo q- d Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal 2'x2'x4" minimum) Yes a No ❑ NA ❑ Casing extends at least 12" above grade Yes No ❑ NA ❑ Casing extends at least 1" above pedestal Yes EV No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes [� No ❑ NA ❑ Graded to allow drainage away from casing SANITARY SEAL: Yes No ❑ NA ❑ Well is sealed between pump and casing Yes Seal between all pipe columns and casing Yes KNo RNAEVf Sounding tube/air vents sealed properly Yes Chlorination port available and sealed properly Yes SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes ❑ No ❑ NA Adequately installed check valve or BFP device No cross connections (ex: chemical feeders hooked to distribution system/a- flood irrigation from domestic supply) Yes Yes ❑ No ❑ No ❑ NA ❑ NA Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA �' MAINTENANCE: Well/Pump visible and protected from damage Yes No ❑ NA ❑ Well/Pump free from excessive vegetation Yes No ❑ NA ❑ FEE E MISCELLANEOUS: Permit drawing represents actual location of well Yes No ❑ No ❑ lf'no' is selected, attach an accurate map to permit No ❑ Permit drawing sufficient to locate well in future Yes Photograph taken and attached to record Yes OTHER: Commenis: Inspected By: G Nv` Title: Received By: Date: r -u A. -inn