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Y <br /> t SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> 1 efopf7wie: (209)468-3420 Fax: (209)468-3433 Web www.sjgov.orq/ehd <br /> PUMP INSPECTION CHECK LIS` <br /> Address: T _ T-- Permit#: Inspection Date: <br /> S30 o0 3Q% <br /> Parameter/Standard Mieets SJC Standards? Comments/Measuren�ejtts/ <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 L] 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 JZ 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 l <br /> check valve or within 3' of well head Yes [� No ❑ �NA❑ <br /> Adequately installed check valve or BFP device Yes No ❑ NA❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution systemlag flood irrigation <br /> from domestic supply) Yes ❑ No 4 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 from excessive vegetation Yes No ❑ NA ❑ <br /> MI�C,ELLANEOUS: i <br /> Permit drawing represents actual location of well Yes J No ❑ <br /> I Permit drawing sufficient to locate well In future Yes No ❑ 11'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 /> i <br /> I <br /> i <br /> Inspected Sy: Title: <br /> Received By: Date: <br />