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S• <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.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Permit#: Inspe tion Date: <br /> Parameter/Standard Meets SJC Standards? Comments/Measure ent <br /> 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 V1 No ❑ NA❑ <br /> Casing extends at least 1" above pedestal Yes ® No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes ® No ❑ I NA❑ <br /> Graded to allow drainage away from casing Yes ® No ❑ INA❑ <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 EN <br /> Chlorination port available and sealed properly Yes ff[ No ❑ NA❑ <br /> SAMPLE TAP AND BACKFLOW PREVENTION: <br /> Non-threaded sample tap between well head and ' , No El NA El <br /> valve or within 3' of well head Yes <br /> Adequately installed check valve or BFP device Yes 09 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 01 <br /> MAINTENANCE: <br /> Well 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 ❑ 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: <br /> Received By: Date: <br /> A/nA In IAG <br />