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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> i efephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Permit#: Inspection Date: <br /> °\S3 o O S° 512,,� <br /> ParameterlStandard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) AYess <br /> No ❑ NA❑ <br /> Casing extends at least 12" above grade No ❑ NA❑ <br /> Casing extends at least V above pedestal Yes 5j INoE1 NA❑ <br /> Free of cracks/contiguous with annular seal Yes A No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes [j No ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between purnp and casing Yes No ❑ INA❑ <br /> Seal between all pipe columns and casing Yes [�) No ❑ NA❑ <br /> Sounding tube/air vents sealed properly - Yes ❑ No ❑ NA[J <br /> Chlorination port available and sealed properly I Yes FJ 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 Eq No ❑ NA❑ <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 /> frorn dornestic supply) Yes ❑ No j NA❑ <br /> Air gap of at least 6" (same as pipe diameter) IYeso No ❑ NA <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 IYes No ❑ <br /> Permit drawing sufficient to locate well in future Iyes 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 />