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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sicgov.orq/ehd <br />PUMP INSPECTION CHECK LIST <br />Address: <br />Parameter/Standard <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes <br />Casing -extends at least 12" above grade Yes <br />Casing extends at least 1" above pedestal Yes <br />Free of cracks/contiguous with annular seal Yes <br />Graded to allow drainage away from casing Yes <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes <br />Seal between all pipe columns and casing Yes <br />Sounding tube/afr vents sealed properly Yes <br />Chlorination port available and sealed properly Yes <br />SAMPLE TAP AND BACKFLOW PREVENTION: <br />Non -threaded sample tap between well head and <br />check valve or within 3' of well head Yes <br />Adequately installed check valve or BFP device Yes <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes <br />Air gap of at least 6" (same as pipe diameter) Yes <br />MAINTENANCE- <br />Well/Pump visible and protected from damage Yes <br />Well/Pump free from excessive vegetation Yes <br />MISCELLANEOUS, <br />Permit drawing represents actual location of well <br />Permit drawing sufficient to locate well in future <br />Photograph taken and attached to record <br />OTHER: <br />Comments: <br />Per i 7nsto <br />>� 0030dR1072 <br />Meets SJC Standards? CommentslMeasurementsl <br />Recommendations <br />No <br />No <br />No <br />No <br />No <br />No U NA <br />No ❑ NA <br />No ❑ NA <br />No FI NA <br />No ❑ NA <br />No ❑ INA <br />Yes_U No <br />Yes No <br />Yes © No <br />If 'no' is selected, attach an accurate map to permit <br />Inspected 13y: 1 0 Title: <br />Received By: Date: <br />