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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:wwwr.sigov.ora/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Permit#. Inspection Date: <br /> z"7r-z. - ' �r " 2?-- 2 -/ -/,(,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 [j? No ❑ NA ❑ <br /> Casing extends at least 1" above pedestal Yes E No ❑ NA ❑ <br /> Free of cracks/contiguous with annular seal Yes No ❑ NA ❑ <br /> Graded to allow drainage away from casing Yes U No ❑ NA ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes [lj` 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 Yes D 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 d <br /> Adequate!y installed check valve or BFP device Yes No ❑ NA ❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes No ❑ NA ❑ <br /> Air gap of at least 6� (same as pipe diameter) Yes ❑ No ❑ NA❑1 ' <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes []JNo ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes No ❑ NA❑ <br /> MISCELLANEOUS: <br /> ' Permit drawing re resents actual location of well Yes Q No ❑ <br /> Permit drawing sufficient to locate well in future Yes[Q No❑ If'rau'isSetecled,attach an accurate map to permit <br /> Photograph taken and attached to record Yes No❑ <br /> ' OTHER: <br /> Comments: <br /> Inspected By: c ^ 1 Title: <br /> Received By: Date: <br /> MI 2095 <br />