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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#: In a tion ate: <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal 2'x2'x4" minimum) Yes [2 No ❑ NA ❑ <br /> Casing extends at least 12" above grade Yes No ❑ NA ❑ <br /> Casing extends at least 1" above pedestal Yes ® No ❑ NA❑ <br /> Free of cracks/contiguous with-annular seal Yes © No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes [A No ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes V No ❑ NA ❑ <br /> Seal between all pipe columns and casing Yes ® No ❑ NA❑ <br /> Sounding tubefair vents sealed properly Yes &( No ❑ NA ❑ <br /> Chlorination port available and sealed properly Yes ❑ No ❑ NA 10 <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 ❑ S <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 +1NA <br /> AWell/Pump free from excessive vegetation Yes [� No F1 <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes-0 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 No ❑ <br /> OTHER: <br /> Comments: / <br /> Inspected By: Title: EVkU n'1n"k'q( * t Aljt <br /> Received By: Date: <br />