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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.segov.oro/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Permit#: Inspection Date: <br /> d ' <br /> Parameter/Standard Meats SJC Standards? om ecom Medan ments/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal 2'x2'x4" minimum Yes ❑ NoEjr NA ❑ <br /> Casing extends at least 12" above grade Yes [9 No ❑ NA ❑ <br /> Casing extends at least 1" above pedestal Yes ❑ No NA❑ <br /> Free of cracks/contiguous with annular seal Yes❑ No ❑ NA Ur <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 WNo ❑ NA❑ <br /> Sounding tube/air vents sealed properly Yes❑ No ❑ NA <br /> Chlorination port available and sealed prOlDerly Yes Wl 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 rNA [D/I <br /> Adequately installed check valve or BFP device Yes No ❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes No ❑ <br /> Air a of at least 6" same as pipe diameter Yes ❑ No ❑ <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage IYes MjNo ❑ INA ❑ <br /> Well/Pump 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 Yes afl No ❑ lif end is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER: <br /> Comments: <br /> Inspected B Title: <br /> Received By: Date: <br /> EH-4200- 8/31/2015 <br />