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r r . 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 Gu noon oioa inner Address/ Permit#:Inspection 717d S / Date: Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes ❑ No ❑ NA ❑ Casing extends at least 12" above grade Yes 0 No ❑ NA ❑ Casing extends at least V above pedestal Yes D 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 R No ❑ NA ❑ Seal between all pipe columns and casing Yes B No ❑ NA ❑ Sounding tubefair vents sealed properly Yes ❑ No ❑ NA 0 Chlorination port available and sealed properly Yes Rt 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 Q Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA Q MAINTENANCE: Well/Pump visible and protected from damage Yes [ INo ❑ INA ❑ Well/Pump free from excessive vegetation Yes No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes 0 No ❑ 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: /- Cornm ts: Inspected By: Title: Received By: Date: Gu noon oioa inner