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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> i efEphone: (209)468-3420 Fax: (209)468-3433 Web:www.sigov.orq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Andress: — Permif#: --- Ins cfion Date: <br /> L\4–T-% °JZ O'� O� Z 3 1 a <br /> � Co� lM dnents/ <br /> ParameierlSfandard eets,JGStandards? Recommendations <br /> EMENT 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 j No ❑ NA❑ <br /> Sounding tube/air vents sealed properly - Yes j No ❑ NA❑ <br /> Chlorination port available and sealed properly Yes Ej 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 El NA[:1 <br /> Adequately installed check valve or BFP device Yes No ❑ I NA❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No [ NA <br /> Air gap of at least 6" (same as pipe diameter) IYes ❑ I No ❑ 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 ElIf'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached'to record Yes No ❑ <br /> OTHER: <br /> Coninnei-its: <br /> i <br /> Inspected By: Title: <br /> Received By: I Date: <br /> I nlnA lnnic <br />