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F SAN JOAQUIN COUNTY A ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone; (209) 468-3420 Fax; (209) 468-3433 Web; www.sigoy.org/ehd PUMP INSPECTION CHECK LIST Address:Inspe O r�-m m rr R.s �,� -T K � CPW Fb D 3 6 ` 0 on ate: 10 113 Parameter/Standard Meets SJC Standards? Comments/Measurements/ 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 No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes U 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 U No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA Q 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 JZ No ❑ NA ❑ Adequately installed check valve or BFP device Yes V 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 NZ 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 No ❑ If Photograph taken and attached to record Yes No ❑ OTHER: - Comments: – n Inspected By: \ GL� NS U I Title: F1,11) ro /) rY 1414 4 -pal k A�, Received