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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.org/ehd PUMP INSPECTION CHECK LIST Address: M A- J7P � 1. ATN -R o P Perm Inspe tion Date: WVOD-3803-7 03 Parameter/Standard Meets SJC Standards? Comments/Measurernents/ Recommendationsmmendatidations 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 1" above pedestal Yes ❑ No 0 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 10 No ❑ NA ❑ Seal between all pipe columns and casing Yes 2 No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA E Chlorination port available and sealed properly Yes ❑ No ❑ NA ❑ SAMPLE TAP AND DACKIFLOW 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 19 MAINTENANCE: Well/Pump visible and protected from damage Yes 7 No ❑ NA ❑ Well/Pump free from excessive vegetation Yes 9 No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes ❑ No ❑ Permit drawing sufficient to locate well in future Yes ❑ No ❑ If `no' is selected, attach an accurate map to permit Photograph taken and attached to record Yes FONo ❑ OTHER: Comments: , re�°'� I Inspected By: CI,,, S r Title: � SJ IS' Received By: Date: