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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.orq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Permit#: Inspection/ate: <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes ❑ No JNA l _ <br /> Casing extends at least 12" above grade Yes No ❑ NAE] <br /> Casing extends at least 1" above pedestal Yes ❑ NoEjY NA❑ <br /> Free of cracks/contiguous with annular seal Yes ❑ No ❑ NA <br /> Graded to allow drainage away from casing Yes ❑ 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 tube/air vents sealed properly Yes ❑ No ❑ NA <br /> Chlorination pbrt available and sealed properly Yes'V 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 system/ag flood irrigation <br /> from domestic supply) I Yes [� No ❑ NA ❑ <br /> Air gap of at least 6" same as pipe diameter) Yes ❑ No ❑ NA Qyj <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damageYes o ❑ NA❑ <br /> WelUPump free from excessive vegetation Yes No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes o ❑ <br /> Permit drawing sufficient to locate well in future Yes o ❑ 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: Title: <br /> Received By: Date: <br />