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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:wvvw.slgov.oMg/ <br /> PUMP INSPECTION CHECK LIST <br /> Address: Permit##: Inspection Date: <br /> 6 06 O2; Z7 ,t7 <br /> Parameter/Standard Meets SJC Standards? CommentslMeasurements/ <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 1" above pedestal Yes No ❑ NA❑ <br /> Free of crackslcontiguous with annular seal Yes No ❑ NA❑ <br /> Graded to allow drainage.away from casing Yes [S) No ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes No ❑ NA❑ _ <br /> Seal between all pipe columns and casing Yes © No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yes 12 No ❑ NA ❑ <br /> Chlorination port available and sealed properly I Yes 5j 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 ❑ INA ❑ <br /> Adequately installed check valve or BFP device Yes No ❑ NA ❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No ❑ NA bU <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No❑] NA <br /> MAINTENANCE: <br /> WelUPump 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 Yes No ❑ <br /> Permit drawing sufficient to locate well in future Yes No ❑ If'no'is selected, attach an accurate map to permit <br /> Photograph taken and attached to record Yes No El <br /> OTHER: <br /> Comments: <br /> Inspected By: Title: jC . <br /> Received BY: Date: <br />