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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.sjgov.orq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Permit##: Inspection Date: <br /> ► 514oa `13P003g2.(19_7 15ztzt1zG1j <br /> Parameter/Standard Meets 5JC Standards? ComrrmenfslMeasurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface sea[ (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 cracks/contiguous with annular seal Yes No El ❑ <br /> Graded to allow drainage away from casing Yes No ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes No❑ NA ❑ <br /> 41 <br /> Seal between all pipe columns and casing Yes M No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yes Lj No ❑ NA❑ <br /> Chlorination port available and sealed properly Yes �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 [Af, No 4 NA❑ <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No❑ NA Ij <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes U No ❑ NA❑ <br /> V1/e11/Pump free from excessive vegetation Yes No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of wellAYes <br /> No ❑ <br /> Permit drawing sufficient to locate well in future No ❑ If'no'is selected, attach an accurate map to permit <br /> Photograph taken and attached to record No ❑ <br /> OTHER: <br /> Comments: -- <br /> I� <br /> 1� <br /> Inspected By: `` Title: <br /> Received By: Date: <br />