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' SIGN JOAQUIN COUNTY <br /> c ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1 868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> T efephone:(209)468-3420 fax: (209)468-3433 Web:www.sjgov.org/ehd <br /> _ PUMP INSPECTION CHECK LIST <br /> Address: � — Permit#: Insp tion Date:^ <br /> � i <br /> ParameterlStandard Meets SJC Standards? CommentslMeasurerner / <br /> Recomrnendations <br /> LENIENT PEDESTAL <br /> Dimensions of surface seal (2'x2'xA" minimum) Yes No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes No ❑ NA❑ <br /> Casing extends at least 1" above pedestal Yes 01 No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes 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 tubelair vents sealed properly - Yes No ❑ NA❑ <br /> Chlorination port available and sealed properly Yes ET No ❑ NA❑ <br /> SAMPLE TAP AND BACKIFLC` W PREVENTION: <br /> Mon-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 j No ❑ NA ❑ <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 <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes No ❑ NA❑ <br /> i iISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes 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 /> I <br /> I <br /> I <br /> Inspected By: Title: <br /> Received By: Date: <br /> hind llnAC <br />