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SAN JOAQU►N 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.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Permit#: Inspection Date: <br /> C. 11. 6 03 a -V v p3lovlz0kai <br /> Parameter/Standard Meets SJG Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal 2'x2'x4" minimum) Yes Ed No ❑ NA ElCasing extends at least 12" above grade Yes No ❑ NA❑ <br /> Casing extends at least 1" above pedestal Yes j No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes [j No ❑ NA❑ <br /> Graded to allow drainage away from casing IYes 9 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 [A No ❑ NA❑ <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 ❑ INA Ej <br /> Adequately installed check valve or BFP device Yes No ❑ INA ❑ <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 d <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes EQ No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes [Jj 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 /> n(n.1 fnAA C <br />