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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.sjjgov.org/ehd PUMP INSPECTION CHECK LIST Address:may, &JCH- C p1 0 03 `� � � Inlption ate; Parameter/StandardComments/Measurements Meets SJC Standards? / Recommendations CEMENT PEDESTAL: Dimensions of surface seal 2'x2'x4" minimum Yes d No ❑ jNA ❑ Casing extends at least 12" above grade Yes Wl No ❑ NA ❑ Casing extends at least V above pedestal Yes 0 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 ❑ NA ❑ - Seal between all pipe columns and casing Yes No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA Q[ Chlorination port available and sealed properly I Yes Ld 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 MAINTENANCE: Well/Pump visible and protected from damage Yes 0 No ❑ NA ❑ Well/Pump free from excessive vegetation Yes lj� 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: Inspected By: Title: ea( AST Received By: Date: