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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 , org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Addres � Per 'f# inspe tion gate . <br /> Comments/Measurements/ <br /> Parameter/Standard Meets SJC Standards ? Recommendations <br /> CEMENT PEDESTAL : <br /> Dimensions of surface seal (2 'x2 ' x4" minimum ) Yes Q No ❑ NA ❑ <br /> Casing extends at least 12" above grade Yes [2 No ❑ NA ❑ <br /> Casing extends at least 1 " above pedestal Yes [2 No ❑ NA ❑ <br /> Free of cracks/contiguous with annular seal Yes No ❑ INA ❑ <br /> Graded to allow drainage away from casing jYes12 jNoE1 INA ❑ <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 0` <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 10 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 ❑ No ❑ NA <br /> MAINTENANCE : <br /> Well/Pump visible and protected from damage YesQ INoE] INAD <br /> Well/Pump free from excessive vegetation Yes [� No ❑ NA ❑ <br /> MISCELLANEOUS : <br /> Permit drawing represents actual location of well Yes Q 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 : <br /> Inspected By : Title : E 14 - kslA dA Ali <br /> Received By: Date : <br /> cu n � nn ❑ iQiton wig <br />