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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.sjgov.org1ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: <br /> Permit#: Ins ec"on Dat . <br /> S• �aM� � Q-� •Trac R.o 0-766718 D3 <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> Recommendafiians <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) IYes No❑ NA❑ <br /> Casing extends at Ieast 12" above grade Yes [V" No❑ NA❑ <br /> Casing extends at least 1" above pedestal Yes ER I No ❑ INA❑ <br /> Free of cracks/contiguous with annular seal Yes ] No ❑ INA❑ <br /> Graded to allow drainage away from casing Yes [/' INo ❑ NA ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes Q No❑ NA ❑ <br /> Seal between all pipe columns and casing Yes lNo❑ NA❑ <br /> Sounding tubelair 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 NA❑ <br /> Adequately installed check valve or BFP device Yes No ❑ NA❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution systemlag 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 [jZrNoo <br /> NA❑ <br /> Well/Pump free from excessive vegetation Yes NA❑ <br /> MISCELLANEOUS: - <br /> Permit drawing represents actual location of well Yes No ❑ <br /> Permit drawing sufficient to locate well in future Yes No ❑ lf'no'is selected�attach anaccurate map to permit <br /> Photograph taken and attached to record Yes [ No ❑ <br /> OTHER: <br /> Comments: <br /> /v u S (t - <br /> Inspected CL4AS Q Title: -' <br /> Received By: Date: <br /> cu t�nn <br />