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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> tefephone:(209)468-3420 Fax: (209)468-3433 Web www.sigov.org/eiid <br /> PUMP INSPECTION CHECK LIST <br /> A:cidreS- Permits: _ s Inspe tion D te: <br /> Parame'Ler/5fandard Meets AJC Standards? <br /> Comments/Measurements] <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes 9 INo [:] NA❑ <br /> Casing extends at least 12" above grade Yes No ❑ NA❑ <br /> Casing extends at least V above pedestal Yes Oj No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes No El NA El <br /> Graded to allow drainage away from casing Yes No ❑ NA❑ <br /> SANITARY SEAL_: <br /> Well is sealed between PLImp and casing Yes Ej INo ❑ 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 poll available and sealed properly Yes No ❑ NA❑ <br /> SAMPLE TAIL AND BACKFLOW PREVENTION: <br /> Non-threaded sample tap between well head and <br /> check valve or within 3' of well head Yes [� lNo ❑ NA ❑ <br /> Adequately installed check valve or BFP device 1'es No ❑ NA❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No A NA <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA <br /> MAINTENANCE: <br /> Veil Pump visible and protected from damage Yes No ❑ NA ❑ <br /> Well/Purnp free from excessive vegetation Yes No ❑ NA ❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes No ❑ <br /> Permit drawing sufficient to locate well in future 1'es No ❑ If'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER: <br /> C oniments: <br /> i <br /> I <br /> Inspected By: Title: <br /> Received 0y: Date: <br /> tt In 1 lel 4 <br />