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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> i efc-phone:(209)468-3420 Fax: (209)468-3433 Web:www.sigov.orq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Permit#: Inspection Date: <br /> w V IJ ID 3.�S l 1 d`� 2 c <br /> Parame�er/Standard Meets SJC Standards? CoinmentslMeasuremenfs/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) 1'es No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes No ❑ NA❑ <br /> Casing extends at least V above pedestal Yes No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes F) No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes No ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing IYes No ❑ NA❑ <br /> Seal between all pipe columns and casing Yes [,� No ❑ NA❑ <br /> Sounding tube/air vents sealed properly - Yes [j No ❑ NA ❑ <br /> Chlorination port available and sealed properly Yes [) No ❑ NA❑ <br /> SAMPLE TAIL AND BACKIFLOW PREVENTION: <br /> Non-threaded sample flap between well head and <br /> check valve or within 3' of well head Yes jNoE1 INAE] <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 /> frorn domestic supply) Yes ❑ No [ NA ❑ <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/Purnp free frorn excessive vegetation Yes No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes 4 No ❑ <br /> Permit drawing sufficient to locate well in futureYes 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 /> i <br /> Inspected By: Title: 1 . <br /> Received By: Date: <br /> M1I+tA!•IAAC <br />