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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.s►gov.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Permit4: Inspection Date: <br /> h; 3 O�Z2°\ g <br /> Parameter/Standard Meets SJC Standards? Comments/Measuremen sl <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 ❑ NA❑ <br /> Free of crackslcontiguous with annular sealYes 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 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 ESJJ No ❑ INA❑ <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 ❑ jNoD NA <br /> MAINTENANCE: <br /> VVellIPump visible and protected from damage Yes No ❑ NA❑ <br /> WeI1/Pump free from excessive vegetation Yes No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes Ej 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: lj� <br /> r <br /> Inspected By: Title: <br /> Received By: Date: <br />