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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.sjqov.orq/ehd PUMP INSPECTION CHECK LIST Address: ( )� _Q /� } /" - ke�n i ("1 G kr ka /•-1"LGi/1�'1 (; P I'`oo��s Ins a on te: 7 ai �. Parameter/standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes No ❑ INA❑ Casing extends at least 12" above grade IYes J No ❑ INA❑ Casing extends at least 1" above pedestal Yes64 No ❑ INA ❑ Free of cracks/contiguous with annular seal Yes 9 No ❑ NA❑ Graded to allow drainage away from casing Yes g No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes No ❑ NA ❑ Seal between all pipe columns and casing Yes�, No El NA El 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 E] Adequately installed check valve or BFP device Yes No ❑ l' ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes F] No❑ NA Air gap of at least 6" (same as pipe diameter) Yes ❑ No❑ NA MAINTENANCE: Well/Pump visible and protected from damage YesR& No ❑ NA❑ Well/Pump free from excessive vegetation Yes No ❑ NA❑ MISCELLANEOUS: - Permit drawing represents actual location of well Yes 411 No ❑ Permit drawing sufficient to locate well in future Yes No ❑ lf'no'is selected,attach an accurate map to permit Photograph taken and attached to record Yes No ❑ OTHER: Comments: Inspected By: CLA, Title:Gi v n rtil h q / Received By: Date: cu n)nn