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Y 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.org1ehd PUMP INSPECTION CHECK LIST Received By: Mu nonn Date: twaress: Per-mit� : Insp coon Date: c 1 R�-�� c��•� �� M3 2� 8 l t8 Parameterl5tandard Meets SJC Standards?Comments/Measurements/ •Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes JZ No ❑ NA ❑ Casing extends at least 12" above grade Yes No ❑ NA ❑ Casing extends at least 1" above pedestal Yes [a 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 YesWoO Seal between all pipe columns and casing YesSounding tube/air vents sealed roperly YesChlorination 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 ❑ 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 [Z 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 0 No ❑ 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes L No ❑ If Photograph taken and attached to record Yes No ❑ OTHER: Comments: Inspected By: Title: - ssg Received By: Mu nonn Date: