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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: wvrw.sigQv.oEq/ehd <br />PUMP INSPECTION CHECK LIST <br />Address: <br />\ o\ �, v. hp l,t p�� AS2.3(p <br />Permit#: <br />�i7 1iDT7 <br />nspection Date: <br />TIZI Z& / �q <br />Parameter/Standard <br />Meets SJC Standards? <br />Comments/Measurements] <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal 2'x2'x4" minimum <br />Yes <br />No ❑ <br />NA ❑ <br />Casing extends at least 12" above grade <br />Yes <br />No ❑ <br />NA ❑ <br />Casing extends at least V above pedestal <br />Yes 0 <br />No ❑ <br />NA El <br />Free of cracks/contiguous with annular seal <br />Yes <br />No ❑ <br />NA ❑ <br />Graded to allow drain age.away from casing <br />Yes [' <br />No ❑ <br />NA ❑ <br />SANITARY SEAL: <br />Well is sealed between pump and casing <br />Yes M <br />No ❑ <br />NA ❑ <br />Seal between all pipe columns and casing <br />Yesj <br />No ❑ <br />NA ❑ <br />Sounding tube/air vents sealed properly <br />Yes <br />No ❑ <br />NA ❑ <br />Chlorination port available and sealed properly I <br />Yes FJ <br />No ❑ <br />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 <br />Yes N/ <br />No ❑ �NA <br />❑ <br />Adequately installed check valve or BFP device <br />Yes [I <br />No ❑ <br />NA ❑ <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) <br />Yes [� <br />No ❑ <br />NA ❑ <br />Air gap of at least 6" (same as pipe diameter) <br />Yes ❑ <br />No ❑ <br />NA D/ <br />