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Y SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 96205-6232 <br /> Telephone; (209)468-3420 Fax. (209)468-3433 Web:www.sigov.orq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: <br /> 9 £ Permit#: Inspection Date: <br /> l7 ` , - SQ-, 00 <br /> 7, Z`- Oil z B I 1 b <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 Yes 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 d�FNo <br /> o ❑ NA❑ <br /> Seal between all pipe columns and casing Yes ❑ NA❑ <br /> Sounding tube/air vents sealed properly Yes V 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 DNA <br /> Adequately installed check valve or BFP device Yes NJ No ❑ NA❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes jNo ❑ NA❑ <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA <br /> MAINTENANCE: <br /> WelUPump visible and protected from damage Yes Q"- No ❑ NA❑ <br /> WelUPump free from excessive vegetation Yes No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes D 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 YesV No ❑ <br /> OTHER: <br /> Comments: <br /> Inspected By: Title: 5 <br /> Received By: Date: <br /> Cu AOnn <br /> nn �n-tom <br />