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SAN JQAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> f efephone:(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.orq/ehd <br /> _ PUMP INSPECTION CHECK LIST <br /> Address: _ Permit#: Inspection Date: <br /> Parameter/Siandard (Meets SJC Standards? Coaiments/Measurementst <br /> Recomme¢ldations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes [�v No ❑ NA❑ <br /> Casing extends at least T' above pedestal Yes [I No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes 0 No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes N 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 [9 No ❑ NA❑ <br /> Sounding tubefair vents sealed properly - Yes I No ❑ NA❑ <br /> Chlorination port available and sealed properly Yes [I 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 F4 No ❑ NA❑ <br /> Adequately installed check valve or BFP device Yes 9 No ❑ NA❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No i NA❑ <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA[I <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No ❑ NA ❑ <br /> Wel Pump free frorn excessive vegetation Yes No ❑ NA❑ <br /> (MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes I No ❑ <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: j <br /> I <br /> \A i <br /> Inspected By: Title: <br /> I <br /> Received By: Date: <br />