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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.slgov.=/ehd PUMP INSPECTION CHECK LIST Address:Perms I SS- 1J E� CAST t 6 RJSR) dc� �38®.RoaIa Tnspe lion aI �I ParameterlStandard Meets SJC Standards? Comments/Measurements/ Iaecommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes 9 No ❑ INA ❑ Casing -extends at least 12" above grade Yes U No ❑ NA ❑ Casing extends at least 1" above pedestal Yes No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes 0 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 ❑1 Sounding tubelair 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 2 No ❑ NA ❑ Adequately installed check valve or BFP device Yes No ElNA [INo cross connections (ex: chemical feeders hooked to distribution systemlag flood irrigation from domestic supply) I iYes ❑ No ❑ NA [2 Air gap of at least 6" (same as pipe diameter) IYesEJ INoDINAR, MAINTENANCE: Well/Pump visible and protected from damage Yes ® No ❑ NA ❑ Well/Pump free from excessive vegetation Yes No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes 0 No ❑ If ono' 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:: Inspected By: GU, Title: Received By: Date: