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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:vwvw.sjgov.o[g///ehd PUMP INSPECTION CHECK LIST Address: Perms r404 ;0/� ctioqDate 3 c �P�Ro Po��s '�`� �nj� 1nj 0 l Paraa.aeterlStandard Meets SJC Standards? Comments/Meas u ream encs/Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes ❑V No ❑ NA ❑ 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 Yes j No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes [a No ❑ INA❑ Seal between all pipe columns and casing Yes ❑ No ❑ NA ❑ Sounding tube/afr vents sealed properly Yes ❑ No ❑ NA [Z Chlorination port available and sealed properly Yes V1 No ❑ NA❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non-threaded sample tap between well head and check valve or within 3' of well head Yes kA 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) Yes ❑ No ❑ NA MAINTENANCE: Well/Pump visible and protected from damage 1 Yes 0 No ❑ NA ❑ Well/Pump free from excessive vegetation Yes No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location,of well Yes No ❑ Permit drawing sufficient to locate well in future Yes Q No ❑ if'no'is selected,attach an accurate map to permit Photograph taken and attached to record Yes 0 No ❑ OTHER: Comments: r�, Is- At> Inspected By: D Title: - - Received By: Date: