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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Tefophone:(209)468-3420 Fax: (209)468-3433 UVEB:www.sjgov.orq/ehd <br /> PUMP INSPECTION CHECK LIS` <br /> P;ddress: Permit#: �^Ins ction bate: <br /> 1 b A 6v) <br /> PaFameter/Standard ftFeeis SJG Standards? CommentslMeasurennents/ <br /> _ Recomrnendatimis <br /> CEMENT PEDESTAL: Q L �h0 <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes ❑ jNoU NA❑ <br /> Casing extends at least 12" above grade Yes ❑ INo t NA❑ <br /> Casing extends at least 1" above pedestal IYes ❑ INo Eb NA❑ <br /> Free of cracks/contiguous with annular sealYes ❑ No NA❑ <br /> Graded to allow drainage away from casing Yes ❑ No I NA❑ <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 El <br /> Chlorination port available and sealed properly Yes No ❑ NA❑ <br /> SAMPLE TAIL AND BACKFLOW PREVENTION: <br /> Non-threaded sample tap between well head and <br /> check valve or within 3' of well head Yes No ❑ INA❑ <br /> Adequately installed check valve or BFP device IYes No ❑ NA❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> X domestic supply) Yes ❑ INof NA El <br /> Air gap of at least 6" (same as pipe diameter) I Yes ❑ INo ❑ NA <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes No ❑ NA❑ <br /> MISCELLANEOUS: i <br /> Permit drawing represents actual location of well Yes No ❑ <br /> Permit drawing sufficient to Locate well in future Yes No [:1If'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER: <br /> Comments: ck <br /> N <br /> Inspected By: Title: <br /> Received By: Date: <br /> - n lnA Inns C <br />