Laserfiche WebLink
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: <br /> ` Permlt#: Inspection Date: <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal 2'x2'x4" minimum Yes 4 No ❑ NA ❑ <br /> Casing extends at least 12" above grade NYesNon <br /> No F-1NA El <br /> Casin extends at least 1" above pedestal 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 um and casingYes No El NA El <br /> Seal between all pipe columns and casing Yes V No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑ NA Uy <br /> Chlorination port available and sealed properly Yes V 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 [9 No ❑ NA ❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes Q/I No ❑ NA ❑ <br /> Air gap of at least 6" (same as pipe diameter) I Yes ❑ I No ❑ NA <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No ❑ INA ❑ <br /> Well/Pump free from excessive vegetation Yes No❑ INA ❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes No ❑ <br /> Permit drawing sufficient to locate well in future Yes No ❑ If'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: t-GL`s <br /> Received By: Date: <br /> EFI-4200- 8/31/2015 <br />