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.' SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> l efephone:(209)468-3420 Fax: (209)468-3433 Web:www.sjqov.oEq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> n Date: <br /> qit <br /> Perm <br /> Address: #: Inspection4, ��� ��� (_o 1 W�o��Z3� 2 <br /> Pa ram eterlStandard [Meets SJG Standards? Comments/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 No ❑ NA❑ <br /> Casing extends at least T' above pedestal Yes No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes 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 ❑ NA❑ <br /> Seal between all pipe columns and casing Yes No ❑ NA❑ <br /> Sounding tube/air vents sealed properly - Yes [I 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 wellhead Yes [j No ❑ NA❑ <br /> Adequately installed check valve or BFP device Yes [j No ❑ NA❑ <br /> No cross connections (ex: chernical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from dornestic supply) Yes ❑ No [ NA❑ <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No ❑ NA ❑ <br /> Well/Pump free frorn excessive vegetation Yes No ❑ NA❑ <br /> MISCELLANEOUS" ' <br /> Permit drawing represents actual location of well Yes T No ❑ <br /> Permit drawing sufficient to locate well in future Yes 01 No ❑ If'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes 4 No ❑ <br /> OTHER: _ <br /> Comments: <br /> UR— <br /> v')��� <br /> Inspected By: Title: -:6 <br /> Received By: Date: <br />