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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.orq/ehd PUMP INSPECTION CHECK LIST Address:'Insoy r ST 510 C k �IJ "W I' o 0 3 O l 3 3 147/Ap Date: Pararneterl5tandard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of* surface seal (2'x2'x4" minimum) Yes No ❑ NA ❑ Casing -extends at least 12" above grade Yes [a No ❑ NA ❑ Casing extends at least 1" above pedestal Yes No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes JZ 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 D No ❑ NA ❑ Sounding tube/afr vents sealed properly Yes ❑ No ❑ NA 2 Chlorination port available and sealed properly Yes 2 No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes [A No ❑ NA ❑ Adequately installed check valve or BFP device Yes FO 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 RZ MAINTENANCE: 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 Q No ❑ if'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes V No ❑ Photograph taken and attached to record Yes [0 No ❑ OTHER: Corry ments: l Inspecte I By: Title: F- H:-- i;eceived By: Date: