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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.si4ov.ort7/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Permit#: Inspection Date: <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal 2'x2'x4° minimum Yes o ❑ NA❑ <br /> Casing extends at least 12" above grade Yes Ef No ❑ NA❑ <br /> Casing extends at least 1" above pedestal Yes No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes No NA❑ <br /> Graded to allow drainage away from casino Yes 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 No ❑ NA❑ <br /> Sounding tube/air vents sealed properly Yes EV .No❑ NA❑ <br /> Chlorination part available and sealed ro erl 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 EX No❑ NA❑ <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 /> 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 ❑ INA❑ <br /> Well/Pump free from excessive vegetation IYes g INo ❑ INA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes No ❑ <br /> Permit drawing sufficient to locate well in future YejsW Po ❑ lf'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes No ❑ _— <br /> OTHER: - -- <br /> Comments: <br /> Ins ected B Title: _ <br /> Received 8 : Date: <br />