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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.sjgov.org/ehd PUMP INSPECTION CHECK LIST Address: �© c>e� T -E - —F n C I"�� I j� ► t Perm' • n3 � q s 6 9nspction ate: lo-�130[13 Parameter/Standard Meets BJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes o/ No ❑ NA ❑ Casing -extends at least 12" above grade Yes [0 No ❑ NA ❑ Casing extends at least V above pedestal Yes [2 No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes [0 No ❑ NA ❑ Graded to allow drainage away from casing Yes M No ❑ NA ❑ SANITARY( SEAL: Well is sealed between pump and casing Yes © No ❑ NA ❑ Seal between all pipe columns and casing Yes [0 No ❑ NA ❑ Sounding tube/afrvents 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 ❑ 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) I Yes ❑ No ❑ NA [0 Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA MAINTENANCE: Well/Pump visible and protected from damage Yes KA I No ❑ INA ❑ 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 accu-rate 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: Received By: Title: Date: