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x 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 By: I Date: cu n'Inn awemn.1r- Address: _ n 0 © M 4,jj' L-rJc lri- ��,Y Perm C, Insp cfiion ate: Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes 0 No ❑ NA ❑ Casing extends at least 12" above grade Yes 0 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 YesWNoEINA Seal between all pipe columns and casing Yes Sounding tube/air vents sealed properly Yes Chlorination port available and sealed roperl Yes SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes ❑ No ❑ =NA9 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 El NA [2 MAINTENANCE: Well/Pump visible and protected from damage Yes -V] No ❑ NA ❑ Well/Pump free from excessive vegetation Yes © No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes [a No ❑ is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes NO ❑ lf'no' Photograph taken and attached to record Yes No ❑ OTHER: Comments: I.� 4r, Inspected By; 0"" V Title: t / Received By: I Date: cu n'Inn awemn.1r-