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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.s►aov.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Add-ress: Permit#: Inspe 'on ate: <br /> ParameterlStandard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes Rf, 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 tj No ❑ NA❑ <br /> Chlorination port available and sealed properly Yes FJ 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 f4No ❑ 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: ff <br /> WelUPump visible and protected from damage Yes No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes &Z No ❑ I 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 tj No ❑ <br /> OTHER: <br /> Comments: <br /> Inspected By: \ �04� `c'� ; >� rjQ Title: ` �cS <br /> Received By: Date. <br /> MW A inn <br /> aoa rine G <br />