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F SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue; Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax; (209) 468-3433 1/P,/eb: www.sigov.oLq/ehd PUMP INSPECTION CHECK LIST Address: s E W OL L l /� t✓ PWc-0 38 J ? � r �7 Inspection Date: Parameter/standard MeetsSJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of' surface seal (2'x2'x4" minimum) Yes &d No ❑ NA ❑ Casing -extends at least 12" above grade Yes © 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 16 No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes 9 No ❑ NA ❑ Seal between all pipe columns and casing Yes No ❑ NA ❑f Sounding tube/air vents sealed properly Yes ❑ No ❑ NA [� Chlorination port available and sealed properly IYes No ❑ INA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes W No ❑ NA ❑ Adequately installed check valve or BFP device Yes E4 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 ❑ No ❑ NA [� 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 Yes No ❑ Photograph taken and attached to record Yes No ❑ OTHER: - Comments: r - Inspecte Title: Received By: Date: