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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.orq/ehd PUMP INSPECTION CHECK LIST A dress: 10 \ Per-mit.iL: Inspection Date: Parameter/StandardCommentslMeasurementst Meets 5JC Standards? Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes No ❑ NA ❑ Casing extends at least 12" above grade YesE4 No ❑ NA ❑ Casing extends at least T' above pedestal Yes No ❑ NA ❑ Free of cracks/contiguous with annular seal ,Yes 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 El 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 ❑ No ❑ NA [t 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 11No ❑ If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes No ❑ Photograph taken and attached to record Yes No ❑ OTHER: Comments: Inspected By: Title: Received By: Date: