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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.orq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Permit#: In e tion Date: <br /> W a�"k l— r , S�Do`77 40 � <br /> ParameterlStandard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal 2'x2'x4" minimum) IYes 0 1 No ❑ INA❑ <br /> Casing extends at least 12" above grade IYes INoEj INA❑ <br /> Casing extends at least V above pedestal Yes [0 jNoE1 INA❑ <br /> Free of cracks/contiguous with annular seal Yes [0 1 No ❑ I NA ❑ <br /> Graded to allow drainage away from casing IYes 4TNo ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes M INoD NA❑ <br /> Seal between all pipe columns and casing IYes M I No 0—f NA❑ <br /> Sounding tube/air vents sealed properly I Yes [ No ❑ NA❑ <br /> Chlorination port available and sealed properly IYes lNo ❑ INA <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 lNo ❑ NA <br /> Adequately installed check valve or BFP device IYesU No ❑ NA❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No❑ INA <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No❑ NA V( <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes V No ❑ INA ❑ <br /> WelllPump free from excessive vegetation Yesd 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 P1 No ❑ <br /> OTHER: <br /> Comme <br /> c <br /> Inspected By: Title: PVS30f 4 + <br /> Received By: Date: <br /> cu n-�nn <br />