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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.smgov.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Q G p Permit#: Inspection Date: <br /> 0 0 0 lU0"ill Ov► n 6 00 1/c Z <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 Z' No ❑ NA ❑ <br /> Casing extends at least 1" above pedestal Yes Ef, No ❑ NA ❑ <br /> Free of cracks/contiguous with annular seal YesROD <br /> o ❑ NA ❑ <br /> Graded to allow drainage awayfrom casingYes NA ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes ET No ❑ NA ❑ <br /> Seal between all pipe columns and casing Yes [✓7 No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yes 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 [Z No ❑ NA ❑ <br /> Adequately installed check valve or BFP device Yes g No ❑ NA ❑ <br /> Any cross connections? (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No ❑ NA Er <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 M' No ❑ NA ❑ <br /> Well/Pump free from excessive ve etation Yes Ea— No ❑ NA ❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes Ef No ❑ <br /> Permit drawing sufficient to locate well in future Yes Ql 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 /> Inspected B : ! Uva C, p (Dur i c, 9.Vv Title: FZ <br /> Received By: Date: '2 z o <br /> EH-4200- 8/31/2015 <br />