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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: Permi rInspe ttion ate: <br /> H izt j -4ve- S ib <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> omments/Measurements/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 ❑ NA❑ Mo QAtt f_ Cvkt,,,& u4ya J.' <br /> Free of cracks/contiguous with annular seal Yes ❑ No ❑ NA ❑ �•.t,c. <br /> Graded to allow drainage away from casing Yes ❑ No ❑ NA ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes 9 No ❑ NA❑ <br /> Seal between all pipe columns and casing Yes R No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑ NA Q <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 0 No ❑ NA❑ <br /> Adequately installed check valve or BFP device Yes Q( 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 0 No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes Wf No ❑ NA ❑ <br /> MISCELLANEOUS: <br /> s <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 No ❑ <br /> OTHER: <br /> Comments: --- <br /> N't C� Y'e` <br /> Inspected By: �l�U Title: �� Jodi t S VQ11 <br /> Received By: Date: <br />