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SAN aJOAQUIN 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 slgov.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Permit#: Inspection Date: <br /> Address: t>� 7 / <br /> c r <br /> G <br /> Comments/Measurements/ <br /> Parameter/Standard Meets SJC Standards? 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 [y No ❑ NA ❑ <br /> Casing extends at least 1" above pedestal Yes y No ❑ NA ❑ <br /> Free of cracks/contiguous with annular seal Yes No ❑ NA ❑ <br /> Graded to allow drainage awayfrom casing Yes No ❑ NA ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casingYes [✓f 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 proper) 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 No ❑ NA ❑ <br /> Adequately installed check valve or BFP device Yes No ❑ NA ❑ <br /> Any cross connections? (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation Yes ❑ No ❑ NA ❑' <br /> from domestic supply) <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑TNo ❑ NA <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes Z No ❑ NA ❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well jYesL7No ❑Permit drawing sufficient to locate well in future No ❑ If'no' is selected,attach an accurate map to permit <br /> Photo raph taken and attached to record No ❑ <br /> OTHER: <br /> Comments: <br /> Inspected By: P M,_JCS - Title: _ 1 <br /> Received By: Date: 2 P Z <br /> EH-4200- 8/31/2015 ' <br />