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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;w% w.sicgov.orq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Permit#: Inspection Date: <br /> L135 A-U� " S0LV__fUrJ 95701 D Y100ol-vitl <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> GEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes Ej No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes 0 No ❑ NA❑ <br /> Casing extends at least 1" above pedestal Yes Ej No ❑ 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 [j INo ❑ NA❑ <br /> Seal between all pipe columns and casing Yes j No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yes [j 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 Ej No ❑ NA ❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes d No❑ NA❑ <br /> Air gap of of least 6" (same as pipe diameter) Yes AV lNo❑ NA[Y <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well IYes No ❑ <br /> Permit drawing sufficient to locate well in futureAYe <br /> No ❑ If'no'is selected, attach an accurate mapto permit <br /> Photograph taken and attached to record No ❑ <br /> OTHER: <br /> Comments: <br /> Inspected By: MWIV I Title: <br /> Received By: Date: <br />