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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.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address Permit#: o.on ate:s �c LInsp(b / )- CA OD -710 .2 <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes JZ No ❑ NA ❑ <br /> Casing extends at least 12" above grade Yes V No ❑ NA ❑ <br /> Casing extends at least V above pedestal Yes U 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 V No ❑ NA ❑ <br /> Seal between all pipe columns and casing Yes No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yes ❑ 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 /Vt, 1 <br /> check valve or within 3' of well head Yes ❑ No NA ❑ <br /> Adequately installed check valve or BFP device Yes Q No ❑ NA ❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No ❑ NA 5� <br /> Air gap of at least 6" (same as pipe diameter) IYes ❑ No ❑ NA <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes Rj No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes No ❑ NA ❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes VINo ❑ <br /> Permit drawing sufficient to locate well in future Yes JA No ❑ If ono'is selected, attach an accurate map to permit <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER: <br /> Comments: <br /> ivy �w►,•�- � <br /> Inspected By: 6w l N Title: <br /> Received By: Date: <br /> r-i u A WIn <br /> orod imine r <br />