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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.slaov.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: 11 Permit#: Inspection Date: <br /> / <br /> zi <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 0" No ❑ NA ❑ <br /> Casing extends at least 1" above pedestal Yes [0 No ❑ NA ❑ <br /> Free of cracks/contiguous with annular seal Yes 0 No ❑ NA ❑ <br /> Graded to allow drainage away from casing Yes v No ❑ NA ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes 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 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 <br /> from domestic supply) Yes ❑ No ❑ NA <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA 0" <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No ❑ NA ❑ <br /> Well/Pump free from excessive ve etation Yes No ❑ NA ❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes Ef No ❑ <br /> Permit drawing sufficient to locate well in future Yes a 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: rr =t�t . S :'t ✓� Title: <br /> Received By: I Date: 9 's% << Z. <br /> EH-4200- 8/31/2015 <br />