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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.org/ehd PUMP INSPECTION CHECK LIST Address: YL (:k S2 -L-7 -wi Permit.: do3RO(o Inspection Date: Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes No ❑ NA ❑ Yes Casing extends at least 12" above grade Yes [I No ❑ NA ❑ Photograph taken and attached to record Casing extends at least T' 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 IYes 9 No ❑ NA ❑ Seal between all pipe columns and casing Yes [4 No ❑ NA ❑ Sounding tube/air vents sealed properly Yes [4 No ❑ NA ❑ 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 f 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 4 No ❑ NA ❑ Air gap of at least 6" (same as pipe diameter) Yes ❑ I No ❑ NA ❑� MAINTENANCE: ,Well/Pump visible and protected from damage Yes E� 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 No Photograph taken and attached to record Yes E� No OTHER: Comments: Ins Received If'no' is selected, attach an accurate map to permit Title: Date: