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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.siclov.orq/ehd PUMP INSPECTION CHECK LIST Address: C7p� ) G 01 S �j �� (; h1 r�/'fi7v L' G GI C /-� L Permi W [ 0 3 � � J Ins a tion ate: O � Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes © No ❑ NA ❑ Casing extends at least 12" above grade Yes Q No ❑ NA ❑ Casing extends at least 1" above pedestal Yes © No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes © No ❑ NA ❑ Graded to allow drainage away from casing Yes Qf No ❑ NA ❑ 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 NZ Chlorination port available and sealed properly Yes KZ 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 g No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes ❑ No ❑ NA EO Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA [a` MAINTENANCE: Well/Pump visible and protected from damage Yes 12 No ❑ INA ❑ Well/Pump free from excessive vegetation Yes No ❑ I NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes ® No ❑ lf'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: c" C Li Inspected By: I Title: Received By: Date: C:u nWn QnaionaG