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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: wvvw.si.gov.org/ehd PUMP INSPECTION CHECK LIST Address: O ILAI (�� n n J �� / ,�Y-lit,J� 16�J�U P xm� . O S 48 I�jn�?i �n Date: Parameter/Standard Meets SJC Standards? Com m ents/Meas urem ents/Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes 4Z No ❑ NA ❑ Casing extends at least 12" above grade Yes Q No ❑ NA ❑ Casing extends at least 1" above pedestal Yes No ❑ NA ❑ Free of cracks/contiguous with annular seal YesZ No ❑ NA ❑ Graded to allow drainage away from casing Yes Q No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes No ❑ NA ❑ Seal between all pipe columns and casing Yes No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA Chlorination port available and sealed properly Yes FZ No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION. Non -threaded sample tap between well head and check valve or within 3' of well head Yes ❑ No NA ❑ n�, ft �/ � Adequately installed check valve or BFP device Yes No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yesio No ❑ 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 ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes No ❑ If'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes M No ❑ Photograph taken and attached to record Yes No ❑ OTHER: Comments: S I c Inspected By: 0-"\ Title: e7) v) YV h WVA' Ci Received By: Date: cu n')nn