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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue; Stockton, CA 95205-6232 Telephone: (209) 468-3420 pax: (209) 468-3433 Web: vwvw.sjgov.orq/ehd PUMP INSPECTION CHECK LIST Address: Ih `T'��1 Permit#: wPoo3 6 Insp ctio Date: b jag�i9 Parameter/Standard Meets SJC Standards? CommenfslMeasurementsf Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes © No ❑ NA ❑ Casing -extends at least 12" above grade Yes [2 No ❑ NA ❑ Casing extends at least 1" above pedestal Yes [A 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 ❑ No ❑ NA ❑ Sounding tubelair 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 © No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes ❑ No ❑ A EO Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ �NA [✓i MAINTENANCE: Well/Pump visible and protected from damage Yes M No ❑ NA ❑ Well/Pump free from excessive vegetation Yes No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location• of well Yes D No ❑ if 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes No ❑ Photograph taken and attached to record Yes No ❑ OTHER: Comments: l Inspected By: Received By: Title: Date: