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f SAN JOAQUIN COUNTY • ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue-, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.slgov.orq/ehd PUMP INSPECTION CHECK LIST Address ( M (T�C 1' I' ^ IV� I Perm/iTco�g-a 6� W �J lnsp ctio Date: I B�rB Parameter/Standard Meets SJC Standards? Comments/Measurements/Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes 9 No ❑ NA ❑ Casing extends at least 12" above grade Yes © No ❑ NA ❑ Casing extends at least 1" above pedestal Yes © No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes 0 No ❑ NA ❑ Graded to allow drainage away from casing Yes ✓❑ No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes g No ❑ INA ❑ Seal between all pipe columns and casing Yes © No ❑ NA ❑ _ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA Q Chlorination port available and sealed properly IYes ® No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes E] 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 2 Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA 2 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 IYes No ❑ if 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future I Yes ❑ No ❑ Photograph taken and attached to record IYes Z No ❑ OTHER: Comment: Inspected By: Title: Received By: Date: FH_a9nn_ 813112015