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i a SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.siAov.org/ehd PUMP INSPECTION CHECK LIST Address: .E • A -R M S I R 0-0),vJ G Perm V W (2 o 3716 1 Ins ction late: Parameter/Standard Meets SJC Standards? Comments/MeasuremenfsJ Recommendations CEMENT PEDESTAL: Dimensions of surface seal 2'x2'x4" minimum) Yes [J No ❑ NA ❑ Casing extends at least 12" above grade Yes V No ❑ NA ❑ Casing extends at least 1" above pedestal Yes No ❑ NA ❑ Free of cracks/contiguous with -annular seal iYes 12 1 No ❑ NA ❑ Graded to- allow drainage away from casing Yes No ❑ INAD SANITARY SEAL: Well is sealed between pump and casing _YesV No ❑ NA ❑ - Seal between all pipe columns and casing Yes V No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA 19 Chlorination port available and sealed properly IYes 0 No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes4A No ❑ NA ❑ Adequately installed check valve or BFP device Yes V 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 No ❑ NA ❑ Well/Pump free from. excessive vegetation Yes &j No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes ® No ❑ if `no' is selected, attach an accurate map to pemmit Permit drawing sufficient to locate well in future Yes Vj No ❑ Photograph taken and attached to record Yes No ❑ OTHER: Comments: Inspected By: Title: &-til"roAMIAW Received By: Date: