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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.sigoy.org/ehd PUMP INSPECTION CHECK LIST Address: r� T 1 �� ►"7� I -bc I b /V ►"7 p r g 45 ^ V�/ Insp&201Date: L17— ParameterlStandard Meets SJC Standards? comjments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes [0 No ❑ NA ❑ Casing extends at least 12" above grade Yes 2 No ❑ NA ❑ Casing extends at least 1" 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 © No ❑ NA ❑ Seal between all pipe columns and casing Yes E' No ❑ NA ❑ Sounding tube/air vents sealed properly Yes W No ❑ NA ❑ Chlorination port available and sealed properly Yes W No ❑ Mold SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes V No ❑ NA ❑ Adequately installed check valve or BFP device Yes 91 No ❑ NA ❑ _ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes ❑ No ❑ NA [a Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA [' MAINTENANCE: Well/Pump visible and protected from damage Yes LZ No ❑ NA ❑ Well/Pump free from excessive vegetation Yes No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes 2 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: Ka, g" Title: ` nn" 19 - Received By: Received Date: