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I- , 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: � Q 1 Pe�rrnini#: �^ r o 0q�J ci Qb Ll 1l -e- oa-71 �wnParameter/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 1" above pedestal Yes [Z No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes No ❑ NA (] Graded to allow drainage away from casing I Yes E0 INO ❑ INA ❑ SANITARY SEAL: Weil is sealed between pump and casing Yes No ❑ NA ❑ Seal between all pipe columns and casing Yes [Z No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No W NA ❑ Chlorination port available and sealed properly Yes No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check Ll J valve or within 3' of well head Yes ❑ No NA I' 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 ❑ I No ❑ I NA Q' MAINTENANCE: Well/Pump visible and protected from damage ]Yes ®t o NA ❑ Well/Pump free from excessive vegetation Yes o NA ❑ ff MISCELLANEOUS: Permit drawing represents actual location of well Yes [I No ❑ Permit drawing sufficient to locate well in future Yes No ❑ 'no' is selected, attach an accurate map to permit 'Photograph taken and attached to record Yes No ❑ OTHER: Comment nlb S Inspectec Received ru n�nn Title: 1AM Date: