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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.siclov.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Permit#: Insp ction ate: <br /> 4b )-0b( S P, 0 0`7,5.33 a s <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal 2'x2'x4" minimum) I Yes No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes No E] NA❑ <br /> Casing extends at least V above pedestal Yes [� No ElNA ❑ <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 INol ❑ INA❑ <br /> Seal between all pipe columns and casing Yes [V No ❑ NA❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑ NAIZ <br /> Chlorination port available and sealed properly Yes No ❑ NA F-1 <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 ❑ 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: <br /> Well/Pump visible and protected from damage Yes U No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes Ll No ❑ NAD - <br /> MISCELLANEOUS: <br /> A❑MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes UINo ❑ <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 /> Com nts: - <br /> VtY-Dhrm.2tile <br /> Inspected By: 0.4-4 Title: SYS SI S <br /> Received By: Date: <br /> Cu n)nn <br />