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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Te%phone: (209)468-3420 Fax: (209) 468-3433 Web:wwv✓.sigov.org/ehd <br /> Address: PUMP INSPECTION CHECK LIST <br /> —' <br /> PermkVkInspection Date: <br /> Parameter/Standard Meets SJC Standards? Comments easurements/ <br /> CEMENT PEDESTAL: Recommendations <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes Q No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes N No ❑ NA❑ <br /> Casing extends at least 1" above pedestal Yes F] No ❑ 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 Yes No ❑ NA❑ <br /> Seal between all pipe columns and casing Yes No ❑ NA❑ <br /> Sounding tube/air vents sealed properly Yes [Y No ❑ NA❑ <br /> Chlorination port available and sealed properly JYes ❑ No ❑ NA LNX <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 0 NA <br /> Adequately installed check valve or BFP device Yes 12 No ❑ NA ❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No X' NA❑ <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 ® No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes ] No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes Q 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 [yc No ❑ <br /> OTHER: <br /> Comments: <br /> aspected By: 6 Title: <br /> received By: Date <br /> Cu n inn <br />