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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: Permit#:Ins t I E{ N w i..t l`� D&7� szoo-76 s-0 Parameter/Standard Meets SJC Standards? CommenisIMPasil me Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes No ❑ NA El extends at least 12" above grade Yes No ❑ t ❑ Casing extends at least 1" above pedestal Yes 2 No ❑ NA ❑ Free of cracks/contiguous with -annular seal Yes 50 No ❑ NA ❑ Graded to- allow drainage nwav frnm cacinr-i I Yac J nrr, I-1 No f—( Date: SANITARY SEAL: Well is sealed between pump and casing Yes No ❑ NA ❑ - Seal between all pipe columns and casing Yes No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA [V Chlorination port available and sealed properly Yes ❑ No ❑ NA EV 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 No ❑ NA ❑ Well/Pump free fromexcessive vegetation Yes No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes 2 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: jL� Title: n/1t4TvIl Received By: Date: