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t <br />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.sjgov.org/ehd <br />RUMP INSPECTION CHECKLIST <br />Address: E <br />Parameter/Standard M <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 V 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/air 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 <br />Well/Pump free from excessive vegetation <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 />Inspected By: D1,w V <br />Received By: <br />Pe ij :003 t7 �0�Tln�,, <br />io <br />41t <br />l 4 <br />Y Comments/Measurements/ <br />eats SJC Standards? Recommendations <br />No L] NA <br />No ❑ NA <br />No NA <br />No I—I NA <br />am■Im■1 <br />Yes kA I No <br />Yes F1 I No <br />NA <br />NA <br />i ka, /9 <br />Yes jN o ❑ <br />Yes ® No ❑ if'no' is selected, attach an accurate map to permit <br />Yes FV1 INo I—I <br />?C &., f-4 l <br />Title: E (1 <br />Date: <br />Ssls <br />ME "I <br />No L] NA <br />No ❑ NA <br />No NA <br />No I—I NA <br />am■Im■1 <br />Yes kA I No <br />Yes F1 I No <br />NA <br />NA <br />i ka, /9 <br />Yes jN o ❑ <br />Yes ® No ❑ if'no' is selected, attach an accurate map to permit <br />Yes FV1 INo I—I <br />?C &., f-4 l <br />Title: E (1 <br />Date: <br />Ssls <br />