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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.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Permit#: Inspection Date: <br /> -q R q►�a I wW� -3) r 'ti;i 11 I QC-, <br /> Parameter/Standard Meets SJC 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 El' No ❑ NA ❑ <br /> Free of cracks/contiguous with annular seal Yes [;J' 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 ❑ No 0 NA ❑ <br /> Seal between all pipe columns and casing Yes ❑ No [a NA ❑ <br /> Sounding tube/air vents sealed proper) Yes [j, No ❑ NA ❑ <br /> Chlorination port available and sealed properly Yes 0" ' 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 ❑ <br /> Adequately installed check valve or BFP device Yes a No ❑ NA ❑ <br /> Any 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 D--' <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes 0', No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes [} No ❑ NA ❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes E 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 /> r 1'`4ir\;rye crac:� Or Cc]si COCtc��tGry 8eG1\ iS bcuk—fin) betweer� <br /> pump and c C Ci"19 <br /> Inspected By: 001 #�P— Title: ,a �4 <br /> Received By: U Date: <br /> EH-4200- 8/31/2015 <br />