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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: Q � �� - Permi I spe tion/Date: C) a Parameter/Standard Meets SJC Standards? Comments/M rnents/ Recommenndatidatieons CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes © No ❑ NA ❑ Casing extends at least 12" above grade Yes © No ❑ NA ❑ Casing extends at least V above pedestal Yes © No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes No ❑ NA ❑ Graded to allow drainage away from casing Yes © 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 [0 No ❑ NA ❑ Chlorination port available and sealed properly Yes ❑ No ❑ NA SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes El ❑ 1NAk4 Adequately installed check valve or BFP device -No Yes jo No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes ❑ No ❑ NA FZI Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA 9 MAINTENANCE: Well/Pump visible and protected from damage Yes 0 No ❑ NA ❑ Well/Pump free from excessive vegetation Yes FA No ❑ INA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes [a No ❑ if 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes No ❑ Photograph taken and attached to record Yes No ❑ OTHER: Comments: Inspected By: Title: j-1 jTi(1 `��► Received By: Date: