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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.silaov.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Permit#: <br /> In Date: <br /> Z J 'A� N �,P�-�c...zu N� S � �rr� `� � $ �7 <br /> Parameter/Standard Meets SJC Standards? Com ments/Measurements/Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x W" minimum) Yes No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes No ❑ NA❑ <br /> Casing extends at least V above pedestal Yes (I No ❑ NA ❑ <br /> Free of cracks/contiguous with annular seal Yes Ej No ❑ NA ❑ <br /> Graded to allow drainage away from casing Yes [d No ❑ NA ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes [I No ❑ NA ❑ <br /> Seal between all pipe columns and casing Yes IjNo ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yes No ❑ NA ❑ <br /> Chlorination port available and sealed properly Yes No ❑ 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 Yes [ No ❑ NA ❑ <br /> Adequately installed check valve or BFP device Yes [j No ❑ NA ❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes [J] No ❑ NA ❑ <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA Ry <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes No ❑ <br /> Permit drawing sufficient to locate well in future Yes No ❑ If`no'is selected, attach an accurate map to permit <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER: <br /> Comments: <br /> A1 1 <br /> Inspected By: nffikl ! �� Title: <br /> Received By: Date: <br />