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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> i etephore:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.orq/ehd <br /> PUMP INSPECTpON CHECK LIST <br /> Address: � � T Permit4: Inspection Date: <br /> �13D <br /> ParameterlStandard IVieets SJC Standards? CommentslMeasurerneviltsl <br /> Recommendations <br /> CEMENT PEDESTAL, <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes No ❑ NA❑ I <br /> Casing extends at least V above pedestal Yes -I- NO ❑ NA❑ <br /> Free of cracks/contiguous with annular seal YesNo ❑ NA❑ <br /> Graded to allow drainage away from casing Yes Ej No ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes No ❑ NA❑ <br /> Seal between all pipe columns and casing Yes Kfi 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 TAP AND BACKFLOW PREVENTION: <br /> Non-threaded sample tap between well head and <br /> check valve or within 3' of well head Yes [� INo ❑ 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 dornestic supply) Yes ❑ No NA <br /> Air gap of at least 6" (same as pipe diameter) IYes ❑ No ❑ INA <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 No ❑ I'1 'no'is Selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER: <br /> Comments: i <br /> Inspected By: Title: 9/ j <br /> i <br /> Received By: Date: <br /> n In 4 In 4 <br />