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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.org/ehd PUMP INSPECTION CHECK LIST Address: ren Pe it#: / inspection)Date: t C QJ P-0 --S- To dI SP.bGT7� �S 16)1';)q114- Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes W1 INq ❑ INA❑ Casing extends at least 12" above grade Yes No ❑ INA❑ Casing extends at least 1" above pedestal Yes &Z No ❑ NA❑ Free of cracks/contiguous with annular seal Yes Z No ❑ NA❑ Graded to allow drainage away from casing Yes hZ No ❑ NA❑ SANITARY SEAL: Well is sealed between pump and casing Yes NZ No ❑ NA❑ Seal between all pipe columns and casing Yes W No ❑ NA ❑ Sounding tube/air vents sealed properly Yes KI No ❑ NA❑ Chlorination port available and sealed properly Yes ❑ No ❑ NA V SAMPLE TAP AND BACKFLOW PREVENTION: Non-threaded sample tap between well head and check valve or within 3' of well head Yes ❑ No ❑ NA [V� 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) 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 0 No ❑ NA ❑ Well/Pump free from excessive vegetation Yesz No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes U No ❑ Permit drawing sufficient to locate well in future YesNo ❑ lf'no'is selected,attach an accurate map to permit Photograph taken and attached to record lYeslNo ❑ OTHER: Comments;, Inspected By: Received By: Date: �u n�nn ❑rid i�n �