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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.orglehd PUMP INSPECTION CHECK LIST Address: T � � P k: �71�ns—pe tion ate: Sr Parameter/Standard Meets 5JC Standards? CommentslMeasurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes [2 No ❑ NA❑ Casing extends at least 12" above grade Yes 0 No ❑ NAE] Casing extends at least 1" above pedestal Yes Z No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes 0 No ❑ NA ❑ Graded to allow drainage away from casing Yes [A No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes F9 No ❑ NA ❑ Seal between all pipe columns and casing Yes a No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA Pq Chlorination port available and sealed properly Yes a No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non-threaded sample tap between well head and - -- check valve or within 3' of well head Yes F--'] No ❑ NA ❑ _ Adequately installed check valve or BFP device Yes Q 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 INo ❑ 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 ❑ Permit drawing sufficient to locate well In future Yes 0 No ❑ If'no'is selected,attach an accurate map to permit Photograph taken and attached to record Yes No ❑ OTHER: Comments: P� � 1 � , Inspected By: �� — --- — -- -- Title: - N Received By: Date: cu n�nn a'147ndr