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M 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 L KI 3T Address 800 C - A� P D � �c�IPv Perm' � 38 14 3 � 7nsp) 3 78ate: �j 3 // ParaineterlStandard Meets SJC Standards? CommentslMeasurements/ Recommendations CEMENT PEDESTAL: Dimensions of' surface seal (2'x2'x4" minimum) Yes [V No ❑ INA ❑ Casing -extends at least 12" above grade Yes Q No ❑ INA ❑ Casing extends at least 1" above pedestal Yes E2 No ❑ INA ❑ 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 ❑ NA ❑ Seal between all pipe columns and casing Yes No ❑ NA ❑ Sounding tubelair vents sealed properly Yes ❑ No ❑ NA ❑ Chlorination port available and sealed properly Yes ❑ No ❑ NA IV _ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes 0 No ❑ NA ❑ Adequately installed check valve or BFP device Yes W No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) I Yes ❑ No ❑ NA [2 Air gap of at least 6" same as pipe diameter) Yes No ❑ NA ❑ - MAINWNANCE: Well/Pump visible and protected from damage Yes No ❑ NA ❑ Well/Pump free from excessive vegetation Yes No ❑ INA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes a No ❑ If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes D No ❑ Photograph taken and attached to record Yes[v� No ❑ OTHER: Comments: Inspected By: Title: -- Received By: Date: