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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.slgov.orq/ehd PUMP INSPECTION CHECK LIST Permit#: Inspe t ��w oFru� K00717qI j z Parameter/Standard Meets SJC Standards? Comments/Measurements/ Qe »It 44- [=U n)nn o»a 1oni c ..uuvia CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes h7 No ❑ NA ❑ Casing extends at least 12" above grade Yes No ❑ NA ❑ Casing extends at least 1n above pedestal Yes No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes ^ No ❑ NA ❑ Graded to allow drainage away from casing Yes No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes K/ No ❑ NA ❑ Seal between all pipe columns and casing Yes No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA Chlorination port available and sealed properly IYes W 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 ❑ 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 V1 No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes 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: , Inspected By: ,�t� Title: Received By: Date: [=U n)nn o»a 1oni c