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y <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 CHECKLIST <br /> Address: Perm' �_Ins ,cptio Date: <br /> 14J <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes M No ❑ NA ❑ _ <br /> Casing extends at least 12" above grade Yes LA No ❑ NA ❑ <br /> Casing extends at least 1" above pedestal Yes E2 No ❑ NA ❑ <br /> Free of cracks/contiguous with annular seal Yes ❑ No ❑ NA ❑ _ <br /> Graded to allow drainage away from casing Yes [A No ❑ INA ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes Q No ❑ NA❑ <br /> Seal between all pipe columns and casing Yes © No ❑ NA❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑ NA [V <br /> Chlorination port available and sealed properly lYes 0 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) I Yes ❑ iNoDINAU <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ I No ❑ INA Ev( <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes R No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes V 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 Yes No ❑ <br /> OTHER: <br /> Comments: <br /> Inspected By: /LL+. j� Title: < of 5SlS 9 QM <br /> Received By: Date: <br /> FH_Agnn_ 8/:11/2015 <br />