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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.orq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Permit#: Inspection Date: <br /> i 5 2'1`1 p, - O&30.2.5r-3 I(J'11 <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements] <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 V above pedestal Yes [I No ❑ NA F1Free of cracks/contiguous with annular seal Yes No ❑ NA❑ <br /> Graded to allow drainage,away from casing JYes No ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes j I No❑ NA❑ <br /> Seal between all pipe columns and casing Yes [4 No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑ NA <br /> Chlorination port available and sealed properly Yes E4 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 A No ❑ NA ❑ <br /> Adequately installed check valve or BFP device Yes [jf No ❑ NA ❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No ❑ NA [J <br /> Air gap of at least 6" (same as pipe diameter) Yes No❑ NA❑ <br /> MAINTENANCE: <br /> VVell/Pump visible and protected from damage Yes INo ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes Ij INo ❑ NA❑ <br /> MISCELLANEOUS: - <br /> Permit drawing represents actual location of well Yes No ❑ <br /> Permit drawing sufficient to locate well in futureAYe <br /> No ❑ If'no'is selected, attach an accurate map to permit <br /> Photograph taken and attached to record No ❑ <br /> OTHER: <br /> Comments: <br /> Inspected By: Title:W V M k'-u <br /> J� <br /> Received By: Date: <br />