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9 . <br /> 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.ora/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: j �� _L Pere o� Ins �on pate: <br /> I L S sic <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes i2No ❑ _NA ❑ <br /> Casing extends at least 12" above grade Yes No ❑ INA ❑ <br /> Casing extends at least 1" above pedestal _YesW No ❑ NA ❑ <br /> Free of cracks/contiguous with-annular seal Yes 0 No ❑ NA ❑ <br /> Graded to allow drainage away from casing Yes [�j No ❑ NA ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes U No ❑ NA❑ <br /> Seal between all pipe columns and casing Yes--KZ No ❑ NA❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑ NA V _ <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 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 ❑ NA V <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No ❑JIN <br /> A❑ <br /> Well/Pump free from excessive vegetation Yes No A❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes Noo <br /> Permit drawing sufficient to locate well in future Yes 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 By: Title: J i <br /> Received By: Date: <br />