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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.s'gov.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Permit#: Inspection Date: <br /> // <br /> 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 e No ❑ NA ❑ <br /> Casing extends at least 1" above pedestal Yes R No ❑ NA ❑ <br /> Free of cracks/contiguous with annular seal Yes ❑ No [0' NA ❑ tfiq-L i t,la [,( r <br /> Graded to allow drainage away from casing Yes &f I No ❑ INA Eff <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes V No ❑ NA ❑ <br /> Seal between all pipe columns and casing Yes No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yes g No ❑ NA ❑ <br /> Chlorination port available and sealed properly Yes [T 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 [Z No ❑ NA ❑ <br /> Adequately installed check valve or BFP device Yes [Z No ❑ NA ❑ <br /> Any cross connections? (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No ❑ NA [K <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA Er <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 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 g No ❑ <br /> OTHER: <br /> Comments: <br /> Inspected By: .�-. 0) a ° Title: r t <br /> Received By: Date: n <br /> EH-4200- 8/31/2015 <br />