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r SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT • 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd PUMP INSPECTION CHECK LIST Received Bv: Date: C:u n)nn R«a��nTc Address: _ I f O� 6 4, - k f # 1W"3252�-1013illY lnsp tion ate: ParameterlStandard Meets SJC Standards?Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes No F1NA ❑ Casing extends at least 12" above grade Yes n 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 ❑ INA ❑ Seal between all pipe columns and casing Yes © No ❑ INA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA 9 Chlorination port available and sealed properly Yes ❑ No NA ❑ A4 It, SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes W] 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 INA Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ INA Q MAINTENANCE: Well/Pump visible and protected from damage Yes ® No ❑ NA ❑ Well/Pump free from excessive vegetation Yes 0 No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes ® No ❑ is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes [ r No ❑ If'no' Photograph taken and attached to record Yes No ❑ OTHER: Comments: ^ t Inspected 3yY- .k \ �0 Title: F _� IJ tt -- Received Bv: Date: C:u n)nn R«a��nTc