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SAN JOAQUIN COUNTY •• ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 96205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sLgov.orq/ehd PUMP INSPECTION CHECK LIST Address: Permit#: In pe'tion Date: S L G S. P-00 Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4U minimum) Yes No ❑ NA ❑ Casing extends at Ieast 12" above grade Yes [ No ❑ NA ❑ Casing extends at least 1" above pedestal Yes D. No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes © No ❑ NA ❑ Graded to allow drainage away from casing No ElNA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes No E] NA ❑ Seal between all pipe columns and casing Yes M No F] NA ❑ Sounding tubelair vents sealed properly Yes ❑ No NA ❑ Chlorination port available and sealed properly Yes U No ❑ NA EE] TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes No ❑ NA ❑ r—' UUV1Uc jNo cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) 1 Co Yes ❑ 1Vu U No ❑ 1%1 L -f NA V Air gap of at least 6" (same as pipe diameter) I Yes ❑ No ❑ NA MAINTENANCE: Well/Pump visible and protected from damage Yes No ❑ NA ❑ Well/Pump free from excessive vegetation Yes I No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes V Yes Yes NoE]Permit No EDif'no' is selected, attach an accurate map to permit No ❑ drawing sufficient to locate well in future Photograph taken and attached to record OTHER: - Com nts: — InspectedBy:w �'s 0 Title: Received Bv: I --.- =W nonn