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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.sjqov.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> L ddress: ! `:" (- �go u n � S�Ck(�N Permi :`: Inspe —7//Late: <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes 2 No ❑ NA ❑ <br /> Casing extends at least 12" above grade Yes LZ No ❑ NA ❑ <br /> Casing extends at least V above pedestal Yes [a No ❑ NA ❑ <br /> Free of cracks/contiguous with annular seal Yes L2 No ❑ NA❑ <br /> Graded to allow drainage away from casing I Yes [2 No ❑ NA ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes a 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 wellhead Yes U No ❑ NA ❑ <br /> Adequately installed check valve or BFP device Yes J1 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 YesNo ❑ NA [:1Well/Pump free from excessive vegetation Yes No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes JZ No ❑ <br /> Permit drawing sufficient to locate well in future Yes LZ 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 /> f�,V I d L I Q.t,,' list) e Inc i G'r e <br /> n <br /> wyyo <br /> Inspected By: cul Title: <br /> Received By: Date: <br /> �u n,)nn <br />