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SAN JOAQUIN COUNTY <br /> `. ENVIRONMEI4TAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Tefephone.(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.or /g ehd <br /> PUMP INSPECTM CHECK LIST <br /> Address: Permi&t-: Inspection Date: <br /> ('�)5 10� <br /> Parameter/standard Beets SJC Standards? OommentslMeasurem ents/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal 2'x2'x4" minimum Yes I No ❑ INAD <br /> Casing extends at least 12" above grade Yes [jJ INo ❑ NA❑ <br /> Casing extends at least V above pedestal Yes Q1 No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes 0 No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes No ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between purnp and casing IYes No ❑ NA❑ <br /> Seal between all pipe columns and casing Yes No ❑ NA❑ <br /> Sounding tube/air vents sealed properly - Yes 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 [�] ND ❑ NA❑ i <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/Pump free from excessive vegetation Yes No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes No ❑ <br /> Permit drawing sufficient to locate well in future Yes N No ❑ If'no'is selected,aftach an accurate map to permit <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER: <br /> Comments., I <br /> Inspected By: Title: <br /> Received By: Date: <br /> '' 11 lnAlnn.iG <br />