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r SAN JOAQUIN COUNTY ' ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.orq/ehd PUMP INSPECTION CHECK LIST Address: 9,0 0 R" MG A� C i � � SDS Pk3s Inspe tion ate: of Parameter/Standard Meets SJC Standards? mments/Measurements/ Recommendations CEMENT 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 1" above pedestal Yes 2 No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes ❑✓ No ❑ NA ❑ Graded to allow drainage away from casing Yes [A No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes U No ❑ NA ❑ Seal between all pipe columns and casing Yes a No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA Chlorination port available and sealed properly Yes JZ No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes W1 lNo ❑ NA ❑ Adequately installed check valve or BFP device Yes jZ 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 MAINTENANCE: Well/Pump visible and protected from damage Yes a No ❑ NA ❑ Well/Pump free from excessive vegetation Yes JZ No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes U No ❑ It'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future ]Yes Yes No ❑ Photograph taken and attached to record K4 No ❑ OTHER: Comments: Inspected By: S® Title: ` A-K(J Received By: Date: [=u n?nn