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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 /> PUMP INSPECTION CHECK LIST <br /> Address: Permi Insp ctio Date: <br /> qq E - Nw, � o kIPo � Poo o /R17 <br /> Com ments/Measurements/ <br /> Parameter/Standard FMeets SJC Standards? Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes 0 No ❑ NA ❑ <br /> Casing extends at least 12" above grade Yes ® No ❑ NA ❑ <br /> Casing extends at least 1" above pedestal Yes No ❑ NA ❑ <br /> Free of cracks/contiguous with annular seal Yes 0 No ❑ NA❑ <br /> Graded to allow drainage away from casing IYes 0 No ❑ NA❑ <br /> SANITARY SEAL: <br /> 'Well is sealed between pump and casing Yes Ej No ❑ NA ❑ <br /> Seal between all pipe columns and casing Yes No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑ NA 11 <br /> Chlorination port available and sealed properly IYes E� INo ❑ 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 No ❑ NA ❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No ❑ NA ❑' <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ 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 0 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 0 No ❑ <br /> OTHER: <br /> Comments: <br /> Inspected By: Cul d Title: <br /> Received By: Date: <br /> FH_a�nn_ <br /> 813112-015 <br />