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s 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.sjgov.m/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Permit#: 1'03J,3o&? <br /> Inspection Date: <br /> >- QT- S TU k - �-C 0 -7 7 3 6 v <br /> Parameter/Standard Meets SJC Standards? Cornments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal 2'x2'x4" minimum) Yes [2 No ❑ NA ❑ <br /> Casing extends at least 12" above grade Yes [2 No ❑ NA❑ <br /> Casing extends at least 1" above pedestal Yes [2 No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes ® No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes N No ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes 0 No ❑ INA ❑ <br /> Seal between all pipe columns and casing Yes ❑i' No ❑ NA❑ <br /> Sounding tube/afr vents sealed properly Yes ❑v' No ❑ NA❑ <br /> Chlorination port available and sealed properly IYes ❑ No ❑ NAV <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 [j�' No ❑ NA❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No ❑ NA 10 <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes [ lNo ❑ NA ❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location•of well Yes No ❑ <br /> Permit drawing sufficient to locate well in future Yes [2 No ❑ if'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record YesU No ❑ <br /> OTHER: <br /> Comments: <br /> Inspected EB3y: 01" <br /> =Titie. 14. S j 1 <br /> Received By: Date: <br />