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s SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 9868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: ` Permit#: Inspe tion�te: <br /> Sc N u ( i c TR y o-n�3 0 8 6336 i8 <br /> Parameter/Standard SJC Standards? Comments/Measurements/ <br /> 7Recommendations <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 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 0 No ❑ NA❑ <br /> Seal between all pipe columns and casing Yes No ❑ NA❑ <br /> Sounding tube/afr 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 ❑ No ❑ NA 0 <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) I Yes ❑ No ❑ NA[ <br /> Air gap of at least 6" same as pipe diameter) 1yes ❑ I No ❑ INA EZ <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes a No ❑ NA❑ <br /> WellIPump free from excessive vegetation Yes [17� No ❑ NA ❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes [ No ❑ <br /> Permit drawing sufficient to locate well in future Yes [Z No ❑ if`no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER: <br /> Co rnents: <br /> Inspected By: S Title: <br /> Received By: Date: <br />