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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: Permit#: Inspe 'on Date: <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum Yes [ No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes No ❑ NA❑ <br /> Casing extends at least 1" above pedestal Yes ❑ No EK NA❑ <br /> Free of cracks/contiguous with annular seal Yes ❑ No S NA ❑ Cy 4J-,j <br /> Graded to allow drainage away from casing Yes ❑ No ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes ❑ANoD <br /> NA❑ <br /> Seal between all pipe columns and casing Yes [�/ NA ❑ <br /> Sounding tube/air vents sealed properly Yes ❑ NA [� <br /> Chlorination port available and sealed properly Yes � 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 fNo ❑ NA❑ <br /> Adequately installed check valve or BFP device Yes [2 No ❑ NA ❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic Supply) IYes ❑ No ❑ NA 0 <br /> Air gap of at least 6" (same as pipe diameter) IYes ❑ No ❑ NA <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes J, INo ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes 2 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 [f No ❑ <br /> OTHER: <br /> Comments: <br /> Cr�1� I <br /> Inspected By: S Title: ` f' <br /> Received By: Date: <br /> Gu n)nn <br />