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y <br /> r SAN JOAQUIN COUNTY <br /> . , a ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 Web:www.si.gov.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Permit#: Inspec' n D e: <br /> -T- <br /> Parameter/Standard Meets SJC Standards? Comments/Measurementsl <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes- ] No ❑ I NA ❑ <br /> Casing extends at least 12" above grade Yes-D No ❑ NA ❑ <br /> Casing extends at least 1" above pedestal Yes g] No [:1 NA ❑ <br /> Free of cracks/contiguous with annular seal Yes-E] No [:1 NA ❑ <br /> Graded to allow drainage away from casing YesCR] 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 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 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 Yes No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes 5j No ❑ NA ❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes ® No ❑ <br /> Permit drawing sufficient to locate well in future Yes 2 No ❑ if'no'is selected, attach an accurate map to permit <br /> Photograph taken and attached to record Yes ® No ❑ <br /> OT R: <br /> omments: <br /> Inspected By: C lA-�'10 0 Dvt L'05 Title: <br /> Recei By: Date: <br /> EH-4200- 8/31/2015 <br />