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P f i 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 CU A7nn st1,44 ron4G Ades Pe Ins ectior Date: Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes 9 No ❑ NA ❑ Casing extends at least 12" above grade Yes [2 No ❑ NA ❑ Casing extends at least I" above pedestal Yes 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 V No ❑ NA ❑ Seal between all pipe columns and casing Yes No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA Chlorination port available and sealed properly IYes V 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 [V Air gap of at least 6" same as pipe diameter) Yes ❑ No ❑ NA IV MAINTENANCE: Well/Pump visible and protected from damage Yes JZ INoo INA ❑ 11 Well/Pump free from excessive vegetation Yes No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes No ❑ If'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes [a' No ❑ Photograph taken and attached to record Yes No ❑ OTHER: Comments: Inspected By: . 0 Title: &V yV'gfi M Received By: Date: CU A7nn st1,44 ron4G