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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 /> Address: <br /> PUMP INSPECTION CHECKLIST 5Rp07735 <br /> Permit#: Inspe tion Date: <br /> 5-0S � I�� � � 3 3 ��n a(r� S f,� a.� <br /> Parameter/Standard 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 IYes V( I No ❑ INA ❑ <br /> Casing extends at least 1" above pedestal Yes V No ❑ INA❑ <br /> Free of cracks/contiguous with annular seal Yes • No ❑ NA ❑ <br /> Graded to allow drainage away from casing Yes M No ❑ NA ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing IYes M JNo0INAFj <br /> Seal between all pipe columns and casing Yes V No ❑ NA❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑ NAL� <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 JNo ❑ NA❑ <br /> Adequately installed check valve or BFP device Yes-0 JNoEj 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 ❑ NAV <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 lNo ❑ <br /> OTHER: _ -- <br /> Comments: -- <br /> c� �l� � <br /> Inspected By: S Title: <br /> Received By Date: <br /> Cu conn <br />