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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: C <br />1A c. �,- <br />Permit#: <br />vu f o b) `tv 9 i 9 <br />Inspection Date: <br />L)//. S/24pzn <br />Parameter/Standard <br />Meets SJC <br />Standards? <br />Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) <br />Yes <br />V <br />No <br />❑ <br />NA <br />❑ <br />Casing extends at least 12" above grade <br />Yes <br />[ff <br />No <br />❑ <br />NA <br />❑ <br />Casing extends at least 1" above pedestal <br />Yes <br />[I <br />No <br />❑ <br />NA <br />❑ <br />Free of cracks/contiguous with annular seal <br />Yes <br />ff <br />No <br />❑ <br />NA <br />❑ <br />Graded to allow drainage away from casing <br />YesI❑" <br />No <br />❑ <br />NA <br />❑ <br />SANITARY SEAL: <br />Well is sealed between pump and casing <br />Yes <br />[tom <br />No <br />❑ <br />NA <br />❑ <br />Seal between all pipe columns and casing <br />Yes <br />No <br />❑ <br />NA <br />❑ <br />Sounding tube/air vents sealed properly <br />Yes <br />2 <br />No <br />❑ <br />NA <br />❑ <br />Chlorination port available and sealed properly <br />Yes <br />2' <br />No <br />❑ <br />NA <br />❑ <br />SAMPLE TAP AND BACKFLOW PREVENTION: <br />Non -threaded sample tap between well head and <br />check valve or within 3' of well head <br />Yes <br />Pf <br />No <br />❑ <br />NA <br />❑ <br />Adequately installed check valve or BFP device <br />Yes <br />1❑" <br />No <br />❑ <br />NA <br />❑ <br />Any cross connections? (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) <br />Yes <br />❑ <br />No <br />❑ <br />NA <br />[� <br />Air gap of at least 6" (same as pipe diameter) <br />Yes <br />❑ <br />No <br />❑ <br />NA <br />MAINTENANCE: <br />Well/Pump visible and protected from damage <br />Yes <br />Er <br />No <br />❑ <br />NA <br />❑ <br />Well/Pump free from excessive vegetation <br />Yes <br />Fi 'I <br />No <br />❑ <br />NA <br />❑ <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well <br />Yes <br />No <br />❑ <br />If'no' is selected, attach an accurate map to permit <br />Permit drawing sufficient to locate well in future <br />Yes Ej <br />No ❑ <br />Photograph taken and attached to record <br />Yes <br />No ❑ <br />OTHER: <br />Comments: <br />Inspected By: r cLn f o ✓ c. t <br />Title: <br />Received By: <br />Date: 0 <br />EH -4200- 8/31/2015 <br />