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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.siclov.orq/ehd PUMP INSPECTION CHECK LIST Address: �� Permi lnsp�cfio{�Date: t.,J Doo �gS �e 3a rr Parameter/Standard Meets SJC Standards? Commments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes ❑ No W NA❑ 5... - 1b� x 3 Casing extends at least 12" above grade Yes [7 No ❑ NA❑ Casing extends at least V above pedestal Yes © No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes v❑ 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 ❑ 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 Q No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes ❑ No ❑ NA[j4 _ Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA R MAINTENANCE: Well/Pump visible and protected from damage Yes 2 No ❑ NA ❑ Well/Pump free from excessive vegetation Yes V �NoEl NA❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes No ❑ Permit drawing sufficient to locate well in future Yes No ❑ If'no'is selected, attach an accurate map to permit Photograph taken and attached to record Yes No ❑ OTHER: Comments: ]] S �I C111 Inspected By: Co Title: Received By: Date: MA n�nn nna i�nti