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SAN 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.sigov.orq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Permit#: Inspection Date: <br /> s 0 ��z� W o03 �0 1�12a1� <br /> Parameter/Standard Meets 5JC Standards? Comments/Measurements/ <br /> Recommendations <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 1" above pedestal Yes E 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 d No ❑ INA❑ <br /> Seal between all pipe columns and casing Yes No ❑ INA ❑ <br /> Sounding tube/air vents sealed properly Yes No ❑ NA❑ <br /> Chlorination port available and sealed properly IYes No ❑ NA❑ <br /> SAMPLE TAP AND BACKFLOW PREVENTION: <br /> Non-threaded sample flap between well head and <br /> check valve or within 3' of well head Yes No ❑ INA ❑ <br /> Adequately installed check valve or BFP device Yes No ❑ INA ❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes No ❑ 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 Fj No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes 9 No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes No ❑ <br /> Permit drawing sufficient to locate well in future Yes [9 No ❑ If'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes 0 No ❑ <br /> OTHER: <br /> Comments: <br /> Inspected By: ` Title: <br /> Received By: Date: <br />