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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT" <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Tefep/roue:(209)468-3420 f=ax: (209)468-3433 Web:www.sigov.oMk!A <br /> _ PUMP INSPECTION CHECK LIST _ _ <br /> P:ddress: Permit#: Inspection Date: <br /> - -t 0 <br /> Comments/Measurements/ <br /> Parameter/Standard Meets SJC Standards? Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes INoEj NA❑ <br /> Casing extends at least 12" above grade I Yes No ❑ NA❑ <br /> Casing extends at least 1" above pedestal qYesNo ElNA[IFree of cracks/contiguous with annular seal No ❑-NA E]Graded to allow drainage away from casing No ❑ INA❑ <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 El <br /> Sounding tube/air vents sealed properly - Yes 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 No ❑ INA❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> X <br /> rom domestic supply) Yes ❑ No [ NA <br /> Air gap of at least 6" (sarne as pipe diameter) Yes ❑ No ff NA <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: I <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 ❑ <br /> OTHER: <br /> Comments: <br /> I <br /> Inspected By: (Title: <br /> Received By: Date: <br /> ­4 <br />