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SAN J0/-QUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 /"ax:(209)468-3433 Web:www.sgov.orq/ehd <br /> PUMP INSPECTION M4ECK LIST <br /> Address: Permit4: Inspection Date: <br /> 3I� wQ 0 3 1 <br /> Parameter/Standard Meets SJG Standards? Comments/Measurementsl <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface sea[ (2'x2'x4" minimum) Yes Et No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes d No ❑ NA❑ <br /> Casing extends at least 1" above pedestal Yes:1 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[:1 <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 lNo ❑ NA❑ i <br /> Adequately installed check valve or BFP device Yes No ❑ NA ❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> frorn domestic supply) Yes ❑ lNo � 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 /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes No El- <br /> Permit <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: <br /> Inspected Ly: Title: <br /> Received By: Date: <br /> 111nA 111AC <br />