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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 tax: (209) 468-3433 Web: www.sigov.orq/ehd <br />PUMP INSPECTION CHECK LIST <br />Address: D <br />Perm <br />�p38 ! 3 1 <br />In <br />VS /// 0/8 te. <br />Parameter/Standard <br />Meets SJC Standards? <br />Com ecom M ndati meats/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) <br />Yes Q <br />No ❑ <br />NA ❑ <br />Casing -extends at least 12" above grade <br />Yes © <br />No ❑ <br />NA ❑ <br />Casing extends at least 1" above pedestal <br />Yes [2 <br />No ❑ <br />NA ❑ <br />Free of cracks/contiguous with annular seal <br />Yes © <br />No ❑ <br />NA ❑ <br />Graded to allow drainage away from casing <br />Yes [] <br />No ❑ <br />NA ❑ <br />SANITARY SEAL: <br />Well is sealed between pump and casing <br />Yes U <br />No ❑ <br />NA ❑ <br />Seal between all pipe columns and casing <br />Yes LZ <br />No ❑ <br />NA ❑ <br />Sounding tube/afr vents sealed properly <br />Yes ❑ <br />No ❑ <br />NA P <br />Chlorination port available and sealed properly <br />Yes [2 <br />No ❑ <br />NA ❑ <br />SAMPLE TAP AND BACKFLOW PREVENTION: <br />Non -threaded sample tap between well head and <br />check valve or within 3' of well head <br />Yes [2 <br />No ❑ <br />NA ❑ <br />Adequately installed check valve or BFP device <br />Yes <br />No ❑ <br />NA ❑ <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic su pl <br />Yes ❑ <br />No ❑ <br />NA <br />Air gap of at least 6" (same as pipe diameter) <br />Yes ❑ <br />No ❑ <br />NA M <br />MAINTENANCE: <br />Well/Pump visible and protected from damage <br />Yes <br />No ❑ <br />NA ❑ <br />__ <br />WelllPump free from excessive vegetation <br />Yes [ <br />No ❑ <br />NA ❑ <br />MISCELLANEOUS: <br />Permit drawing represents actual location• of well <br />Yes <br />No ❑ <br />If 'no' is selected, attach an accu"rate map to permit <br />Permit drawing sufficient to locate well in future <br />Yes [2 <br />No ❑ <br />Photograph taken and attached to record <br />Yes <br />No ❑ <br />OTHER: <br />Comments: <br />l <br />r <br />Inspected By: S <br />Title: A131, tit t <br />Received By: <br />Date: <br />