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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: <br />Permit#: <br />Inspection Date: <br />Parameter/Standard <br />Meets SJC Standards? <br />ComrbentslMeasurementsl <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) <br />YesEj <br />No ❑ <br />NA ❑ <br />Casing extends at least 12" above grade <br />Yes <br />No ❑ <br />NA ❑ <br />_ <br />Casing extends at least V above pedestal <br />Yes <br />No ❑ <br />NA ❑ <br />Free of cracks/contiguous with annular seal <br />Yes <br />No ❑ <br />NA ❑ <br />Graded to allow drainage.away from casing <br />Yes [j <br />No ❑ <br />NA ❑ <br />SANITARY SEAL: <br />Well is sealed between pump and casing <br />Yes <br />No ❑ <br />NA ❑ <br />Seal between all pipe columns and casing <br />Yes <br />No ❑ <br />NA E]Sounding <br />tube/air vents sealed properly <br />Yes <br />No ❑ <br />NA ❑ <br />Chlorination port available and sealed properly <br />Yes <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 [ INo❑ <br />INA <br />❑ <br />Adequately installed check valve or BFP device <br />Yes 11 jNoE1 <br />INAE=I <br />