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SANT JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Tele/)hone:(209)468-3420 Fax: (209)468-3433 yl/eb:www.sjgov.orq/ehd <br /> _ PUMP INSPECTION! CHECK LIST <br /> Address: Permit#.: Inspetion Da e: <br /> Parameter/Standarci Meets SJC Standards? Cotnr�entslMeasureMents/ <br /> Recommendations <br /> (',EMENT" PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes A No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes No ❑ NA❑ <br /> Casing extends at least 1" above pedestal Yes t4 No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal 4esNo ElNA❑ <br /> Graded to allow drainage away from casing No ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing IsNo ❑ NA❑ <br /> Seal between all pipe columns and casing No ❑ NA❑Sounding tubelair vents sealed properly No ❑ NA❑Chlorination poll available and sealed properly No ❑ NA❑ <br /> SANTLE TAP AND BACKFLOW PREVENTION: <br /> Non-threaded sample tap 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 ❑ NA ❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution systemlag 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 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 /> Pen-nit 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 I No ❑ <br /> OTHER: <br /> Comments: - — <br /> Inspected By: Title: 1ri� <br /> Received By: Date: <br /> . n/nA 1nnAC <br />