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SAFE JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.slgov.orq/ehd <br /> _ PUIMP INSPECTION CHECK LIST <br /> Address: Permit#: Inspection Date: <br /> IlA` <br /> ParameterlStandard Meets SJC Standards? commentslMeasuremen'csl <br /> Recommeiidations <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 V above pedestal Yes No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes ff No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes [A No ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes Ej JNo ❑ NA❑ <br /> Seal between all pipe columns and casing Yes [ No ❑ I 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❑ 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 ❑ No [ NA <br /> Air gap of at least 6" (same as pipe diameter) jYesE1 INo ❑INA <br /> MAINTENANCE: <br /> Well visible and protected from damage Yes No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yesq INoDINAD <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes 111 No ❑ <br /> ,Permit dram ing sufficient to locate well in future Yes 11 No ❑ If'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record IYes No ❑ <br /> OTHER: <br /> Comments: I <br /> Inspected By: Title: S <br /> Received By: Date: <br />