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F t 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.s' ov.or /ehd PUMP INSPECTION CPECK LIST Date: u Q�� e I 0j I PWPU03ssq,,Djn�� Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes [B No ❑ NA ❑ Casing extends at least 12" above grade Yes No ❑ NA ❑ Casing extends at least V above pedestal Yes 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 IYes El Seal between all pipe columns and casing Yes 5� A[]NA Sounding tubelair vents sealed properly Yes ❑ Chlorination port available and sealed properlyYes SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes Pj 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 Ej (MAINTENANCE: Well/Pump visible and protected from damage Yes LlNo ❑NA Well/Pump free from excessive vegetation Yes No ❑ NA MISCELLANEOUS: Permit drawing represents actual location of well Yes ® No Permit drawing sufficient to locate well in future Yes No Photograph taken and attached to record Yes No OTHER: Comments: Inspectec Received so If 'no' is selected, attach an accurate map to permit Title: - Date: Ir =u n)nn aroaronaG