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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 !Address - 0 � 3-� G� - �jrr'' (� K I v Per f o o �6 8 i Inspe tion ate: r ��i Parameter/Standard Meets SJC Standards? Comments/Measurements) Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes tj No ❑ NA ❑ Casing extends at least 12" above grade IYes 2 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 4 No ❑ NA ❑ Seal between all pipe columns and casing Yes [0 No ❑ NA ❑ Sounding tube/air vents sealed properly Yes V- No ❑ NA ❑ Chlorination port available and sealed properly Yes ❑ No ❑ NA EV 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 J( 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 ❑ lf'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: / Inspected By: Oso Title: &V10n Z99 Received By: Date: MJ nonn