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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.si-gov.org/ehd PUMP INSPECTION CHECK LIST AddLess: hY� I A -A !D /� S L L� MJ IUh Peep d 3 81 ps�egt� Date: Parameter/Standard Meets SJC Standards? Comments/Measurements/ CEMENT PEDESTAL: 1j Dimensions of surface seal (2'x2'x4" minimum) Yes JZ No 9 NA ❑ Los �IX2/ Casing extends at least 12" above grade Yes 0 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 YesVj No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes N No ❑ NA ❑ 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 ❑ 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) IYes ❑ No ❑ NA Z Air gap of at least 6" (same as pipe diameter) IYes ❑ No ❑ NA _ MAINTENANCE: Well/Pump visible and protected from damage Yes Qf No ❑ NA ❑ Well/Pump free from excessive vegetation Yes EV No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes ® No ❑ If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes [�j No ❑ Photograph taken and attached to record Yes 0' No ❑ OTHER: Comments: CL Inspected By: Vc" Title: Received By: Date: =U A9nn Pjgimn4G