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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.ong/ehd PUMP INSPECTION CHECK LIST Address:Perms E. H 4 S j o GK I b 86 Inspe tion ate: 03 ��o c� Parameter/Standard [Meets SJC Standards? CommentslMeasurernents/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal 2'x2'x4" minimum) Yes No ❑ NA ❑ Casing -extends at least 12" above grade Yes © No ❑ NA ❑ Casing extends at least 1" above pedestal Yes 2 No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes © No ❑ NA ❑ Graded to allow drainage away from casing Yes [0 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 tubelair vents sealed properly Yesij 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 BFP device Yes No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution systemlag flood irrigation from domestic supply) Yes ❑ I No ❑ INA [M' Air gap of at least 6" (same as pipe diameter) Yes ❑ INo ❑ INA MAINTENANCE: Well/Pump visible and protected from damage Yes No ❑ NA ❑ Well/Pump free from excessive vegetation Yes No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes No ❑ If `no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future —YesU No ❑ Photograph taken and attached to record Yes Q No ❑ OTHER: Comments: Inspected By: lith SQ Received By: Title: Date: