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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: 0( U -(614r miLc R� L.-NDci No ❑ Perm W 0:0,3%6x2. Insp ctiopp Date: 111;2 / Parameter/Standard Yes GA Meets SJC Standards? NA ❑ Comments/Measurements/ Recommendations CEMENT PEDESTAL: Yes ❑ No ❑ NA Yes ❑ Dimensions of surface seal (2'x2'x4" minimum) NA] Yes No ❑ NA ❑ No ❑ Casing extends at least 12" above grade Yes 2 No ❑ NA ❑ Casing extends at least V above pedestal Yes W Yes (Z No ❑ NA ❑ Well/Pump free from excessive vegetation Free of cracks/contiguous with annular seal No ❑ Yes 0 No ❑ NA ❑ Graded to allow drainage away from casing Yes 0 No ❑ NA ❑ No ❑ SANITARY SEAL: Well is sealed between pump and casing Yes 2 No ❑ NA ❑ Yes (0 Seal between all pipe columns and casing Yes GA No ❑ NA ❑ Yes Sounding tube/air vents sealed properly Yes ❑ No ❑ NA Yes ❑ Chlorination port available and sealed properly IYes NA] No ❑ NA ❑ Yes ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes (0 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 MAINTENANCE: Well/Pump visible and protected from damage Yes W No ❑ NA ❑ Well/Pump free from excessive vegetation Yes [0 No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes U No ❑ if 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes 2 No ❑ Photograph taken and attached to record Yes LZ No ❑ OTHER: Comments:/ Inspected By: Vouk J� Title: E 0 ►"r��j q,.,/ � Received By: Date: