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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.=/ehd PUMP INSPECTION CHECK LIST Address: -� -5-5-0C- - co 0 c s sn r� �1 Permi �1 insp tion ate: Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes U No ❑ INA ❑ Casing extends at least 12" above grade Yes a No ❑ NA ❑ Casing extends at least V above pedestal Yes D No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes No ❑ NA ❑ Graded to allow drainage away from casing Yes W1 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 ❑ 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 Adequately installed check valve or BFP device Yes 41 No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply Yes ❑ No ❑ NA Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA [0 MAINTENANCE: Well/Pump visible and protected from damage Yes ®No ❑ NA ❑ Well/Pump free from excessive vegetation Yes V No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Permit drawing sufficient to locate well in future Photograph taken and attached to record OTHER: Yes No ❑ Yes No ❑ Yes No ❑ if 'no' is selected, attach an accurate map to permit Comments: Inspected By: GLt t Received By: Title: 1-S Date: