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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6Z32 <br /> Telephone:(209) 468-3420 Fax: (209)468-3433 Web:www.9jgov.orq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Permit#: _ Inspection Date: <br /> 11 <br /> ParameterlStandard Meets SJC Standards? <br /> Com ments/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 T' above pedestal Yes ❑ No ❑ NA ❑ <br /> Free of cracks/contiguous with annular seal Yes 0 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 El No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly - Yes ❑ No ❑ NA ❑ <br /> Chlorination port available and sealed properly Yes ❑ No ❑ NA 0 <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 ❑ No ❑ NA ❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ Xo NA M4 <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA El <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 Yes 0 No ❑ <br /> Permit drawing sufficient to locate well in future Yes 0 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 /> Inspected By: Ph mto Title: <br /> Received By: Date: <br /> CLI Aonn OMAl7nAC <br />