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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.sjgov.org/ehd PUMP INSPECTION CHECK LIST L Pn— �., ! n Address: I 66 U 1g, Pnitp n 'n pe tion Date: Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations GEMENT 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 V above pedestal Yes [0 No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes 0 No ❑ NA ❑ Graded to allow drainage away from casing Yes d No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes [a No ❑ NA ❑ Seal between all pipe columns and casing Yes [a' No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA [a" Chlorination port available and sealed properly I Yes No ❑ NA ❑ 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 [a' MAINTENANCE: Well/Pump visible and protected from damage Yes Qi No ❑ INA ❑ Well/Pump free from excessive vegetation Yes No ❑ INA ❑ MISCELLANEOUS: Permit drawing represents actual location of well IYes ®I No ❑ if `no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future YesNo ❑ Photograph taken and attached to record Yes No ❑ OTHER: Comments: Inspected By: 0, S O Title: ( eJ Received By: Date: F -:u n)nn