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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 Address: r— Perm Inspection Date: tib SSE Eb ►� r �rf C- I � D�038 6 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 2 No ❑ NA❑ Casing extends at least V above pedestal Yes No ❑ NA❑ Free of cracks/contiguous with annular seal Yes 2 No ❑ NA❑ Graded to allow drainage away from casing Yes [M No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes S2 No ❑ NA❑ Seal between all pipe columns and casing Yes [17 No ❑ NA ❑ Sounding tube/air vents sealed properly Yes 2 No ❑ NA ❑ Chlorination port available and sealed properly Yes W] No ❑ NA❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non-threaded sample tap between well head and check valve or within 3' of well head Yes P 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) I Yes ❑ No ❑ NA Q Air gap of at least 6" (same as pipe diameter) jYesEj No ❑ NA[✓� MAINTENANCE: _ Well/Pump visible and protected from damage Yes [a' No ❑ NA❑ Well/Pump free from excessive vegetation Yes No ❑ NA❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes Ej� No ❑ Permit drawing sufficient to locate well in future Yes 2 No ❑ If'no'is selected,attach an accurate map to permit Photograph taken and attached to record Yes [Z No ❑ OTHER: Comments: Inspected By: 6Alt Title: F►� Received By: Date: CLI n7nn R/']'I lon'IF