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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.si-ov.org/ehd PUMP INSPECTION CHECK LIST Address: �d I S 5q-ck Tb oJ� �-I Perm' w oa37 37 insp tion,Date: o Parameter/Standard Meets SJC Standards? Comments/Measurements/Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes [� 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 No ❑ NA ❑ Graded to allow drainage away from casing YesE0 No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes KZ 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 Yes �j 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 [Z 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 No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes LZ No ❑ lf'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future YesNo ❑ Photograph taken and attached to record Yes No ❑ OTHER: Comments: Inspected By: Title: Received By: Date: CU A7nn Q Ili i r7nIa