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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT" 1868 East Hazelton Avenue, Stockton, CA 95205-6232 T efephone:(209)468-3420 Fax: (209)468-3433 Iffeb:www.sigov.org/ehd PUMP INSPECTION CHECK LIST Address: � � — - � Permith: _Inspection Date:^ �,1ooO k. �v0 . C QO 0o 3qS��. -C go Param eterlStandard Meets SJC Standards? CommenfslMeasurenne ts! Recommendations GEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes No ❑ NA❑ Casing extends at least 12" above grade Yes 01 No ❑ NA❑ Casing extends at least 1" above pedestal Yes No ❑ NA❑ Free of cracks/contiguous with annular seal Yes No ❑ NA❑ Graded to allow drainage away from casing I Yes It lNo ❑ INA❑ sANIT RY'SEAL: Well is sealed between pump and casing Yes Kh No ❑ INA❑ Seal between all pipe columns and casing Yes No ❑ NA❑ I 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 [� No ❑ NA❑ Adequately installed check valve or GFP device 1YesJ No ❑ INA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation X rom domestic supply) Yes ❑ No 1� 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/Pl lrnp free from excessive vegetation Yes M No ❑ NA ❑ MI sCELLANE'OUS: 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 i Photograph taken and attached to record Yes No ❑ OT 11 E R: Comments: ' I "N Inspected By: A%N )1W Title: \ Received By: Date: