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SAN JOAQUIN'COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> 1 efep/tette:(209)468-3420 Fax: (209)468-3433 1410b:vvww.sjgov.orq/ehd <br /> PUMP INSPECTION CHECK LIS _ <br /> P:ddress: xR (Permit#.:� Inspection Date: <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 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 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 j No ❑ �NAEI <br /> Adequately installed check valve or BFP device jYes1j No ❑ 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) I Yes ❑ No ❑ NA <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation IYes 4 No [:11 NA❑ <br /> MISCELLANEOUS: l <br /> Permit drawing represents actual location of well Yes No ❑ <br /> Permit drawing sLifficient to locate well in future 4YesNo ❑ If'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record I No ❑ <br /> OTHER: <br /> Comments: <br /> I <br /> Inspected By: Title: <br /> Received By: Date: <br /> - /11•t.t InnA C <br />