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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.s4gov.org/eh <br /> PUMP INSPECTION CHECK LIST <br /> Address: Peerrrmita#: Inspection Date: <br /> 7375 /0 /v <br /> Parameter/Standard Meets SJC Standards? Comments/Measure en / <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 fK1 No ❑ NA [:1 <br /> Graded to allow drainage away from casing IYesE I No ❑ I NA ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes E] 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 <br /> check valve or within 3' of well head Yes ❑ No ® INA ❑ <br /> Adequately installed check valve or BFP device Yeso No ❑ NA ❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) I Yes ❑ No ❑ NA <br /> Air gap of at least 6" (same as pipe diameter) IYes ❑ No ❑ NA 911 <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes E 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 No ❑ <br /> OTHER: <br /> Comments: <br /> Inspected By: �— Title: <br /> Receiv y: Date: <br /> EH-4200- 8/31/2015 <br />