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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.sigov.orq/ehd <br /> :l )) PUMP INSPECTION CHECK LIST <br /> Address I S K ) F(7 �S C�L�/" P� r(9v 8 l�on late: <br /> Parameter/Standard Meets SJC Standards? Comments/M eas u rem ents/Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal 2'x2'x4" minimum) Yes El No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes 0 No ❑ NA❑ <br /> Casing extends at least 1" above pedestal Yes © No ❑ NA ❑ <br /> Free of cracks/contiguous with annular seal Yes ® No ❑ NA ❑ <br /> Graded to allow drainage away from casing Yes © No ❑ NA ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes No ❑ NA ❑ <br /> Seal between all pipe columns and casing Yes ✓❑ No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yes M No ❑ NA ❑ <br /> Chlorination port available and sealed properly Yes 2 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 V1 No ❑ NA ❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) I Yes ❑ No ❑ NA 2 <br /> Air gap of at least 6" same as pipe diameter) jYesE1 No ❑ NA <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 0 No ❑ If'no'is selected, attach an accurate map to permit <br /> Photograph taken and attached to record Yes [2 No ❑ <br /> OTHER: <br /> Comments: <br /> Inspected By: 5� Title: -V" <br /> Received By: Date: <br /> F:u nonn <br />