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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 Web:www.sigov.org/ehd <br /> _ PUMP INSPECT110"d CHECK LISA' <br /> P: 'dress: Permit#: Inspection Date: <br /> s a C3 22 A, <br /> Parameter/Standard Meets SJC Standards? Coin ments/Measurements! <br /> {recommendations <br /> CEMENT PEDESTAL: � <br /> Dimensions of surface seal (2'x2'x4" minirnum) Yes No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes [ No ❑ NA❑ <br /> Casing extends at least V above pedestal Yes No ❑ NA❑ <br /> Free of cracks/contiguous with annular- seal Yes [j 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 Ej 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 `SAP AND BACKFLOW PREVENTION: <br /> Non-threaded sample tap between well head and <br /> check valve or within 3' of well head Yes F� No ❑ NA❑ <br /> Adequately installed check valve or 13FP device Yes No ❑ NA ❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution systenVag flood irrigation <br /> from domestic supply) Yes ❑ No NA❑ <br /> Air gap of at least 6" (same as pipe diameter) iYes ❑ No ❑ NA <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No ❑ NA ❑ <br /> Well/Pump free frorn excessive vegetation Yes No ❑INA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes No ❑ <br /> Permit drawing sufficient to locate well in future A/esNo ElIf'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record No ❑ <br /> OTHER: <br /> Comments: <br /> i e• <br /> Inspected By: T tI . <br /> Received By: Date: <br /> nlnA fn/A C <br />