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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> a 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 Web:www.sogov.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Permit#: Inspecti n ate: <br /> �,1 � bLQ,t L �5ti�� ID 9 3 <br /> Parameter/Standard Meets SJC 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 1" above pedestal Yes ❑ No ❑ NA ❑ <br /> Free of cracks/contiguous with annular seal Yes Q 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 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 d No ❑ NA ❑ <br /> Ad-quately installed check valve or BFP device Yes No ❑ NA ❑ <br /> Nc ;ross connections (ex: chemical feeders <br /> hc.cked to distribution system/ag flood irrigation <br /> frr r,i domestic supply) Yes ❑ No 1� NA ❑ <br /> gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA <br /> MAINTENANCE: <br /> :jrrp visible and protected from damage Yes No El NA ❑ <br /> vveli/r-ump free from excessive vegetation Yes No ❑ NA ❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes INo ❑ <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: �� r <br /> wMQ <br /> Inspected B Title: S� <br /> Received By: Date: <br /> EH-4200- 8/31/2015 <br />