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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: Perm't#: Inspection Date: <br /> 1 ,R 1pt it E's Kb rr m,,-,�- C�- VJ F coy -7 6 <br /> 11111:7 1 t-1— <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4n minimum) Yes No r-1NA El <br /> Casing extends at least 12" above grade Yes No F-1NA ❑ <br /> Casing extends at least 1" above pedestal Yes ® No ❑ NA❑ <br /> Free of cracks/contiguous with-annular seal Yes W No ❑ NA❑ <br /> ra flow drainage away from casing Yes [6 No ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes No ❑ NA ❑ <br /> Seal between all pipe columns and casing Yes No ❑ NA❑ <br /> Sounding tubefair vents sealed properly Yes ❑ No ❑ NA "V° f <br /> Chlorination port available and sealed properly I 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 NA ❑ <br /> Adequately installed check valve or BFP device Yes JA 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[K <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 Q 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: CA, tj so Title: ~' ,wN&Itk All f <br /> Received By: Date: <br />