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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.slgov.org/ehd <br />PUMP INSPECTION CHECK LIST <br />Non -threaded sample tap between well head and <br />check valve or within 3' of well head <br />Yes ❑Jf <br />No ❑ <br />NA ❑ <br />Adequately installed check valve or BFP device <br />Yes <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 <br />MAINTENANCE: <br />Well/Pump visible and protected from damage <br />Yes <br />No ❑ <br />NA ❑ <br />Well/Pump free from excessive vegetation <br />Yes K) <br />No ❑ <br />NA ❑ <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well <br />Yes <br />INo ❑ <br />If'no' is selected, attach an accurate map to permit <br />Permit drawing sufficient to locate well in future <br />Yes <br />No ❑ <br />Photograph taken and attached to record <br />Yes Ej <br />No ❑ <br />OTHER: <br />Comments: <br />i <br />-- <br />Inspected By: <br />Title: <br />Received By: <br />Date: <br />