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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 {max. (209) 468-3433 Web: www.sigov.orq/ehd PUMP INSPECTION CHECK LIST Address: �$ I I..7 I �1 Per, t .� n W C)olD ns No Date: p(b78 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 [0 No ❑ NA ❑ Casing extends at least V above pedestal Yes 9 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 No ❑ INA ❑ Seal between all pipe columns and casing Yes [� No ❑ NA ❑' Sounding tubelair vents sealed properly Yes ❑ No ❑ NA Chlorination port available and sealed properly IYes ❑ No ❑ NAM SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes ❑ No ❑ NA [17� Adequately installed check valve or BFP device Yes No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution systemlag flood irrigation from domestic supply) Yes ❑ No ❑ NA Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA MAIWENANCE: Well/Pump visible and protected from damage Yes No ❑ NA ❑ Well/Pump free from excessive vegetation Yes[1� No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location• of well Yes U 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: / l , Inspected By: v Title: tis Received By: Date: