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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.sjgov.orq/ehd PUMP INSPECTION CHECK LIST Address: , jf W ��„• Pe�i \ O r lnspectio ate: tg Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Pj Dimensions of surface seal (2'x2'x4" minimum) Yes'A No NA ❑ b's ..2 X .2 Casing extends at least 12" above grade Yes R No ❑ NA ❑ Casing extends at least 1" above pedestal Yes ® No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes [A No ❑ NA ❑ Graded to allow drainage away from casing Yes R- No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes [:4 No ❑ NA ❑ Seal between all pipe columns and casing Yes [V No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA ❑ Chlorination port available and sealed properly I Yes ❑ INo ❑ I 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 Adequately installed check valve or BFP device Yes EZ No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) I 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 ® No ❑ NA ❑ Well/Pump free from excessive vegetation Yes No -1 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 [A No ❑ OTHER: Comments: Inspected By: C(,(� j Title: • '�• S i.3 Received By: Date: