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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:vAm.sigov.orq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Permit#: Inspection Date: <br /> Address:_ _ <br /> S«� ., <br /> JMeets SJC Standards? Comments/Measurements/ <br /> Parameter/Standard 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 — NOD NA❑ <br /> Casing extends at least T' above pedestal Yes No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes a No [INA❑ <br /> Graded to allow drainage away from casing Yes No ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes No ❑ NA❑ <br /> Seal between all pipe columns and casing Yes No ❑ NA❑ <br /> Sounding tube/air vents sealed properly - Yes ❑ No ❑ NA <br /> Chlorination port available and sealed properly I Yes ❑ No ❑ NA <br /> EV <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 /> ELY <br /> Adequately installed check valve or BFP device Yes [lx No ❑ NA❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes No E] NA ❑ <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ I No ❑ NA <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 o ❑ <br /> Permit drawing sufficient to locate well in future Yes M o ❑ <br /> if'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes E� No ❑ <br /> OTHER: <br /> Comments: <br /> Inspected By: Title: <br /> Date: <br /> Received By: <br /> 8/3112015 <br />