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Y 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.orq/ehd <br /> PUMP INSPECTION CHECK LIST } p <br /> Address: � � � �h � Perm� 6*: <br /> �,cti° �qe: <br /> ParameterlStandaard Meets SJC Standards? Comments/Measurements/ C <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes U NoWNAF� <br /> Casing extends at least 12" above grade Yes ® NoCasing extends at least 1u above pedestal Yes 0 NoFree of cracks/contiguous with annular seal Yes r❑ No <br /> Graded to allow drainage away from casing Yes Z 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 V No ❑ NA❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No ❑ NA[f <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA[� <br /> MAINTENANCE: <br /> WeIVPump visible and protected from damage Yes bZ No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes }F No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes No ❑ <br /> Permit drawing sufficient to locate well in future Yes L 0 No ❑ if`no'is selected, attach an accurate map to permit <br /> Photograph taken and attached to record Yes Z No ❑ <br /> OTHER: <br /> Comments: <br /> Inspected E rJS Title: <br /> Received By: Date: <br /> Mu ��nn <br />