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1 SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DE=PARTMENT <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 /> Ad ress: PermiInspection Date: <br /> Parameter/Standard Meets SJC Standards? Comments/Measurernents/ <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 INo ❑ NA ❑ <br /> Casing extends at least 1" above pedestal Yes INo ❑ 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 IYes No ❑ NA ❑ <br /> Seal between all pipe columns and casing Yes W No ❑ NA ❑ ❑— <br /> Sounding tube/air vents sealed properly Yes [Z 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 10 <br /> Adequately installed check valve or BFP device Yes No ❑ NA ❑ <br /> No cross connections (ex: chernical feeders <br /> hooked to distribution system/2g flood irrigation <br /> from domestic supply) Yes ❑ No ❑ NA <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ INA [VI <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No ❑ NA ❑ <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 No ❑ if'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER: - <br /> Comments: <br /> l <br /> Inspected By: ( Title: ��• A � <br /> Received By: _ _ <br /> Date: <br /> U-1-1-4200- 8/31/2015 <br />