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t SAN JOAQUIN COUNTY '= ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sigov.org/ehd PUMP INSPECTION CHECK LIST Address: Per i Inspe tion ate: �a c k- 6 �c1 S'f 6 c k Tb ,;�POa3?! 3-d' a 211, r 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 ❑ c 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 ® No ❑ NA ❑ Seal between all pipe columns and casing Yes No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA Q' Chlorination port available and sealed properly Yes Q No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non-threaded sample tap between well head and check valve or within 3' of well head Yes [2 No ❑ NA ❑ Adequately installed check valve or BFP device Yes 2 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 L2 No ❑ NA ❑ Well/Pump free from excessive vegetation Yes 0 No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes U No ❑ Permit drawing sufficient to locate well in future Yes © No ❑ If ono'is selected, attach an accurate map to permit Photograph taken and attached to record Yes [Z No ❑ OTHER: Comments: S c Inspected By: aA. 0 Title: Received By: Date: