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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.sigov.org/ehd PUMP INSPECTION CHECK LIST Address i O (� W, L ou r A V c i EC R Permit PD -D38 4- q Z Inspe to[date: js /e 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 [2' No ❑ NA ❑ Casing extends at least 1" above pedestal Yes 0 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 Vz] No ❑ NA ❑ Seal between all pipe columns and casing Yes [2 No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA [✓]f Chlorination port available and sealed properly Yes U No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes Q lNo ❑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 ❑ -5( NA [� MAINTENANCE: Well/Pump visible and protected from damage Yes ® No ❑ NA ❑ Well/Pump free from excessive vegetation Yes 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: S Title: — H • is s 1Z k Received By: Date: C:u n)nn