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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.olq/ehd PUMP INSPECTION CHECK LIST y ifN AD C ;moi., ck Well/Pump visible and protected from damage PermiCOT Inspectio DatWPe ParameterlStandard Meets SJC Standards? Comm ents/Measurementsl Recommendations CEMENT PEDESTAL: No ❑ NA MISCELLANEOUS: Dimensions of surface seal 2'x2'x4" minimum Yes jj'Po N'o NA ❑ - Casing extends at least 12" above grade Yes [�NA qn ❑Casing extends at least 1" above pedestal Yes ®NA Comments: ❑ Free of cracks/contiguous with -annular seal IYes ® INo ❑ INA ❑ Graded to- allow drainage away from casing Yes ® No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casingW;VZ NA ❑ - Seal between all pipe columns and casingNA ❑ Sounding tube/air vents sealed properlyNA [j4 Chlorination port available and sealed properNA 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 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 [I]' MAIN 1 CIVAINUI= 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 N'o Permit drawing sufficient to locate well in future Yes No Photograph taken and attached to record Yes No OTHER: Comments: Inspected By Received Bv: If'no' is selected, attach an accurate map to permit Title: Date: