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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.sagov.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Permit#: Ins ection Date: <br /> 4j-) <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> _i 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.[ No ❑ NA ❑ <br /> Casing extends at least 1" above pedestal Yes 0- No ❑ NA [_1 <br /> Free of cracks/contiguous with annular seal Ye5E No ❑ NA ❑ <br /> Graded to allow drainage away from casing Yesv] No ❑ NA ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yeses] No ❑ NA ❑ <br /> Seal between all pipe columns and casing Yes ej No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yeses No ❑ NA ❑ <br /> Chlorination port available and sealed properly Yes K 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 [n- No ❑ NA ❑ <br /> Adequately installed check valve or BFP device Yes'❑ No ❑ NA ❑ <br /> No 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 ❑ NAE <br /> MAINTENANCE: <br /> wql <br /> Well/Pum 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 f�j 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 B - t�GW �- � Title: c7t L07,(f <br /> Received By: Date: f I LLI 2,-2, <br /> I <br /> EH-4200- 8/31/2015 <br />