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SAN J0AQUIN 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.sjgoy.orglehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Permit#: - fns esti n Date: <br /> Parameter/Standard Meets SJC Standards? Coin mentslMeasurements/ <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 V above pedestal Yes No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal AreNoElNA[IGraded to allow drainage away from casing No ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes No ❑ INA❑ <br /> Seal between all pipe columns and casing Yes & No ❑ INA❑ <br /> Sounding tube/air vents sealed properly Yes N No ❑ NA❑ <br /> Chlorination port available and sealed properly I Yes No ❑ NA❑ <br /> SAMPLE TAP AND BACKFLOW PREVENTION: <br /> Non-threaded sample flap between well head and <br /> check valve or within 3' of well head Yes [� No ❑ NA❑ i <br /> Adequately installed check valve or BFP device Yes [f No ❑ NA❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No Et NA❑ <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No 0 N 14 <br /> MAINTENANCE: <br /> Weil/Pump visible and protected from damage Yes No ❑ NA❑ <br /> V1/ell/Pump free from excessive vegetation Yes [ ] No ❑ NA❑ j <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well IYes 4 No ❑ <br /> Permit drawing sufficient to locate well in future Yes No ❑ 11'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: <br /> Received By: Date: <br />