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S s 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: �/ C �f C.A LoJ PI'�I r o 0 3—?)_ � i7 on U � 0 ate: Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes Casing extends at least 12" above grade Yes Casing extends at least V above pedestal Yes Free of cracks/contiguous with annular seal Yes Graded to allow drainage away from casing Yes SANITARY SEAL: Well is sealed between pump and casing Yes Seal between all pipe columns and casing Yes Sounding tube/air vents sealed properly Yes Chlorination port available and sealed properly Yes SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes Adequately installed check valve or BFP device Yes No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes Air gap of at least 6" (same as pipe diameter) Yes MAINTENANCE: Well/Pump visible and protected from damage Ye Well/Pump free from excessive vegetation Ye MISCELLANEOUS: Permit drawing represents actual location of well Permit drawing sufficient to locate well in future Photograph taken and attached to record OTHER: Comments: MEMBELMAIM No El INA❑ No [I INA[:1 No U INA No F] INA I• • ■ 71 Yes U No Lj Yes F,� No ❑ If'no' is selected, attach an accurate map to permit Yes n Non u_�.c( ulca Inspected By: �t-ti S Title: Received By: Date: FHS,)nn- w.moni5 No El INA❑ No [I INA[:1 No U INA No F] INA I• • ■ 71 Yes U No Lj Yes F,� No ❑ If'no' is selected, attach an accurate map to permit Yes n Non u_�.c( ulca Inspected By: �t-ti S Title: Received By: Date: FHS,)nn- w.moni5