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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: Permlt#: Inspection pate: <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> CEMENT PEDESTAL: Recommendations <br /> Dimensions of surface seal 2'x2'x4" minimum Yes No ❑ NA❑ <br /> Casing extends at least 12" above grade YesNo❑ NA❑ <br /> Casingextends at least 1" above pedestal Yes No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal tata <br /> NA El <br /> Graded to allow drainage awayfrom casin NA ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes No ❑ NA❑ <br /> Seal between all pipe columns and casing Yes [D/ No ❑ NA❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑ NA <br /> Chlorination port available and sealed properly 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 10" <br /> Adequately 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 Q� No ❑ NA❑ <br /> Air gap of at least 6" same as pipe diameter Yes ❑ No ❑ NA <br /> MAINTENANCE: <br /> Well/PLIMP visible and protected from dams e Yes No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes No ❑ NA ❑ <br /> MISCELLANEOUS: <br /> Permit drawingrepresents 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: Title; <br /> Received By: Date: <br /> EH-4200- 8131/2015 <br />