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K 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.org/ehd PUMP INSPECTION CHECK LIST Address: 0 0 \j VA (j- �-� , � Per it D D31151 3 (nspe on D te: 2 0 Parameter/Standard Meets SJC Standards? Comments/MeasurementsI Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes 5Z No ❑ NA ❑ Casing extends at least 12" above grade Yes ® No ❑ NA ❑ Casing extends at least 1" above pedestal Yes No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes W No ❑ NA ❑ Graded to allow drainage away from casing j Yes 9 No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes 9 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 lYes 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 0 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 Q( No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well No ❑ lf'no' is selected, attach an accurate map to permit —Yeso Permit drawing sufficient to locate well in future Yes 2 No ❑ Photograph taken and attached to record Yes No ❑ OTHER: Comments: - -- Inspected By: Cu., JI Title: (J Received By: Date: Mu n'Wnn Q roa Mna c