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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Tefephone:(209)468-3420 Fax. (209)468-3433 14/6b:vvww.sjgov.orq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Permit :^ ion^InspectDate: <br /> q <br /> Parameter/Standard Meets SJC SfGrdards? I Commet;ts/Measurements/ <br /> Recommendations <br /> GEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes ❑ No NA❑ <br /> Casing extends at least 12" above grade Yes ❑ No NA❑ i <br /> I <br /> Casing extends at least V above pedestal Yes ❑ No 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 pump and casing Yes No ❑ NA❑ <br /> Seal between all pipe columns and casing Yes a INo ❑ NA❑ <br /> Sounding tube/air vents sealed properly - Yes No ❑ NA <br /> Chlorination port available and sealed properly Yes ❑ No ❑ INA �! <br /> SAMPLE TAP AND BACKFLOW PREVENTION: <br /> Non-threaded sample tap between well head andl � <br /> check valve or within T of wellhead Yes ❑ No ❑ NA d I' <br /> Adequately installed check valve or BFP device Yes No ❑ NA❑ <br /> No cross connections (ex: chemical feeders I <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No NA❑ i <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA U <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes INo ❑ INA❑ <br /> Well/Purnp free from excessive vegetation Yes INo ❑ NA❑ <br /> ,MISCELLANEOUS: l <br /> Permit drawing represents actual location of well Yes No ❑ <br /> 1 Permit drawing sufficient to locate well in future Yes No ElIf'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes EA No ❑ i <br /> OTHER: I <br /> Comments: <br /> AAA <br /> i <br /> I <br /> Inspected By: J V6 1 Title: <br /> Received By: Date: <br />