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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.org/ehd PUMP INSPECTION CHECK LIST Address. Sto L� �� S21 Permit.#:Inspection S (' 6 �S Date: Z 13 1 Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes Et No ❑ NA ❑ Casing extends at least 12" above grade Yes ANo ❑ NA ❑ Casing extends at least 1" above pedestal Yes 14No ❑ 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 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 [Jj 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 ❑ 1NoF1 NA IJ MAINTENANCE: Well/Pump visible and protected from damage Yes No ❑ NA ❑ Well/Pump free from excessive vegetation Yes No ❑ INA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes Et INo ❑ If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well In future Yes Oil No ❑ Photograph taken and attached to record Yes No ❑ OTHER: Comments: Inspected By: Title: Received By: Date: