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SAN JOAQUIN COUNTY <br /> ENv1RONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax;(209)468-3433 Web www.sigov.org/ehd <br /> PUMP INSPECTION CFIECK LIS`` <br /> P:ddress: Permit#: Inspection Date: <br /> Parameter/Standard Meets SJG Standards? CotrnmentslMeasurementsl <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes Ej No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes No ❑ NA❑ <br /> Casing extends at least V 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 ET 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 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❑ t�L <br /> Adequately installed check valve or BFP device Yes [X No ❑ NA❑ <br /> No cross connections (ex: chernical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No 14 NA❑ <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA 12 <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No ❑ NA❑ <br /> WeWPump free from excessive vegetation Yes Y1 No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permifi drawing represents actual location of well Yes No ❑ <br /> Permit dravving sufficient to locate well in future Yes No ❑ I 'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER.: <br /> Comments,* i <br /> Inspected lay: Title: <br /> Received By: Date: <br /> A/nA InPAC <br />