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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.sjgov.orjq/ehd PUMP INSPECTION CHECK LIST Address:f PLO 03 �� -1,i r) CIJ O)` of Peri mitv&• "? q VV �J e: 9nspe 1OW1111Y Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal 2'x2'x4" minimum) Yes ® No ❑ INA ❑ Casing -extends at least 12" above grade Yes U 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 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/afr 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 [0 Adequately installed check valve or BFP device Yes No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution systemlag flood irrigation from domestic supply) I Yes ❑ No ❑ NA 2 Air gap of at least 6" same as pipe diameter) IYes ❑ No ❑ NA [a' MAINTENANCE: Well/Pump visible and protected from damage Yes No ❑ NA ❑ Well/Pump free from excessive vegetation Yes [0 No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location• of well Yes [2 No ❑ if `no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes U No ❑ Photograph taken and attached to record Yes No ❑ OTHER: Comments: Inspected By: CIM Title: E,fTcjllSt Received By: Date: