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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: Perm! <br /> t#D b�� <br /> In ectiongDate: <br /> 2 Par� L01I S'fC <br /> ParameterlStandard Meets SJC Standards? Comments easurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) iYes No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes © No ❑ NA❑ <br /> Casing extends at least 1" above pedestal Yes [0 No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes 10 JNo ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes No ❑ NA El <br /> Seal between all pipe columns and casing Yes RZ No E] NA❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No [Z NA❑ <br /> Chlorination port available and sealed properly Yes a No ❑ NA❑ <br /> SAMPLE TAP AND BACKFLOW PREVENTION: <br /> Non-threaded sample tap between well head and 41 <br /> check valve or within 3' of well head Yes ❑ LNNo*NA❑: r"o <br /> Adequately installed check valve or BFP device Yes ❑ oNA❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ NoJE-1NA <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No❑ NA[0 <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes V1 No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes JZ 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 ❑ lf'no'is selected, attach an accurate map to permit <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER: - <br /> Comments: <br /> Inspected By: ala-+ d TitleAss t i 4-cv <br /> Received By: Date: <br /> cu e--)nn <br />