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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.slgov.org/ehd PUMP INSPECTION CHECK LIST Addres B s0 E-c�Dc �, LID Pe �iM38 3 Inspe ion Date: d .7 0,71le Parameter/StandardMeets SJC Standards? Com m ents/Meas u rem encs/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) YesE9 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 Yes No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes [0 No ❑ NAE] " 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 ❑ 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 6A Adequately installed check valve or BFP device Yes Qj 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 j 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: o.' SV Title: S r Received By: Date: =u nonn oY]anniC