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Y SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.slgov.orcl/ehd PUMP INSPECTION CHECK LIST Address: 0. 5 v�3 �� Permit#_ �MfL— ParameterlStandard Date: V 3a5HZ Meets SJC Standards? CommentslMeasurementsl 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 V above pedestal Yes[j No ❑ NA❑ Free of cracks/contiguous with annular seal Yes No ❑ NA❑ Graded to allow drainage away from casing Yes &Y No ❑ NA❑ SANITARY SEAL: Well is sealed between pump and casing Yes 11 No ❑ NA❑ Seal between all pipe columns and casing Yes No ❑ NA❑ Sounding tubefair vents sealed properly Yes � No ❑ NA ------------------------- Chlorination port available and sealed properly Yes [Y 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 No ❑ NA❑ No cross connections (ex: chemical feeders hooked to distribution systemlag flood irrigation from domestic supply) Yes ❑ No ❑ NA D/ Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA[t MAINTENANCE: WeIVPump visible and protected from damage Yes ILNo ❑ NA❑ Well/Pump free from excessive vegetation Yes [,a No ❑ NA❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes No ❑ Permit drawing sufficient to locate well in future Yes0jNoFj If`no'is selected,attach an accurate map to permit Photograph taken and attached to record Yes ❑ No ❑ OTHER: Comments: Inspected By: Title: Received By: Date: cu norm az�iona�