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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.orq/ehd <br /> PUMP INSPECTION ICON CI IECK LIST <br /> Address: Permit##: Inspecti99n Date: <br /> S O S :JACk TO Al K.D MA-tJT67CA v"7 055 l! 11,f/oor? <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ --- <br /> Recommendations <br /> CEMENT PEDESTAL, V � <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 ® No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes 0 No ❑ NA ❑ <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 [2 No ❑ NA ❑ <br /> Sounding tubefair vents sealed properly Yes ❑ No ❑ NA W <br /> Chlorination port available and sealed properly Yes V 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 S ( 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 ❑ NAM <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA Q <br /> MAINTENANCE: <br /> Well/Pump 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 No ❑ lf'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes ❑Vt No ❑ <br /> 0THE} : <br /> Comments: <br /> �R ec S A,mvfLl� <br /> Inspected By: Title: ( � AJ�tJ T2•.'� <br /> Received By: Date: <br /> CLI n)nn <br /> iona r_ <br />