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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 LIS` <br /> Address. T Permit#. �q(-Zztkl <br /> nspection Date: <br /> 5500 5. A a oo3 S�� <br /> PararneterlStandaard Meets SJC standards? Cornments/Measurements/ <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 [0 1 No ❑ NA❑ <br /> Casing extends at least T' above pedestal Yes No ❑ NA❑ <br /> Free of cracks/contiguous with annular sealYes No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes 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 ❑ NA❑ <br /> Sounding tube/air vents sealed properly - Yes 9 No ❑ NA❑ <br /> Chlorination port available and sealed properly Yes M 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 j No ❑ NA ❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No o NA ❑ <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA Id <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well iYes No ❑ <br /> Permit drawing sufficient to locate well in future IYes No ❑ If'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record IYes No ❑ <br /> OTHER: <br /> Comments: <br /> Inspected By: `' Title: '�l5� <br /> Received By: __ Date: <br />