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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.slclov.orq/ehd PUMP INSPECTION CHECK LIST Address:/� /� �i 9 Pso Inspe7tion �9 gat e: (/ - ' 4'i 1 //J & � /� g r /! Parameter/Standard Meets 5JC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes NoANACasing extends at least 12" above grade Yes [' NoCasing extends at least V above pedestal Yes E' No Free of cracks/contiguous with annular seal Yes 0 No ❑ NA ❑ Graded to allow drainage away from casing Yes No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes E' No ❑ NA ❑ Seal between all pipe columns and casing Yes a No ❑ NA ❑ Sounding tube/air vents sealed properly Yes WT No ❑ NA ❑ Chlorination port available and sealed properly l 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 [Z 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 ❑ NA Air gap of at least 6" same as pipe diameter) Yes ❑ No ❑ NA MAINTENANCE: Well/Pum visible and protected from damage Yes &4 No ❑ NA ❑ Well/Pump free from excessive vegetation Yes No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes Fv No ❑ lf'no' is selected, attach an accurate map to perm z Permit drawing sufficient to locate well in future Yes No ❑ Photograph taken and attached to record Yes No ❑ OTHER: Comments: r Inspected By: You, go Title: Received By: Date: r -u Bonn n/z4 imine G