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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.orq/ehd PUMP INSPECTION CHECK LIST A dress. 0' - WA - ),11%1))&J4 ParameterlStandard Meets SJC Standards? Permit#: Inspectiop Date: 0 8 6l012 /l CommentslMeasurementsf Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes V No ❑ NA ❑ Casing extends at least 12". above grade Yes [Z No ❑ NA ❑ Casing extends at least 1" above pedestal Yes EA 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/air vents sealed properly Yes No ❑ NA ❑ Chlorination port available and sealed properly Yes ❑ No ❑ NA Q SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes o ❑ NA 9 - Adequately installed check valve or BFP device Yes RoEl NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes ❑ No A Air gap of at least 6" (same as pipe diameter) Yes ❑ No NNA MAINTENANCE: Well/Pump visible and protected from damage Yes Q( No ❑ NA ❑ Well/Pump free from excessive vegetation Yes [� No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes No ❑ 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future ]Yes Yes Ej, No ❑ if Photograph taken and attached to record No ❑ OTHER: Comments: / Title: �VI1 �jIYVlRiel�. Received By: . I Date: