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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.sigov.orglehd PUMP INSPECTION CHECK LIST Address:Permit#: nn \S Lo 5'�(�f�`L jN " �J 3q 3l li2pecfionDafe: ParameterlStandard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4n minimum) YesEj No ❑ NA ❑ Yes ENJ Casing extends at least 12" above grade Yes Ef, No ❑ NA ❑ Photograph taken and attached to record Casing extends at least 1" above pedestal Yes N No ❑ NA ❑ Free of crackslcontiguous with annular seal Yes No ❑ NA ❑ Graded to allow drainage away from casing Yes fV No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes N.jNo ❑ NA ❑ Seal between all pipe columns and casing Yes Ej No ❑ NA ❑ Sounding tubefair 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 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 ❑ jNoEj INA MAINTENANCE: Well/Pump visible and protected from damage Yes No ❑ NA Well/Pump free from excessive vegetation Yes No ❑ NA MISCELLANEOUS: Permit drawing represents actual location of well Yes ENJ INo Permit drawing sufficient to locate well in future Yes No Photograph taken and attached to record Yes No OTHER: Comments: Ins If 'no' is selected, attach an accurate map to permit Title: Received By: . I Date: