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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.sj oq v.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: I Permit;#: Inspection Date:: <br /> Parameter/Standard Meets SJC Standards? Comments/Mea urementst <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes 01 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 crackslcontiguous with annular seal Yes No ❑ NA❑ <br /> Graded to allow drainage,away from casing Yes No ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes �f No ❑ NA❑ <br /> Seal between all pipe columns and casing Yes No ❑ NA ❑ <br /> Sounding tubelair vents sealed properly Yes [I 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 ❑ No ❑ INA [� <br /> Adequately installed check valve or BFP device Yes 9 No ❑ NA ❑ N <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 ❑ INoD 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 91 No ❑ <br /> Permit drawing sufficient to locate well in future YesNo F-1If`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: V , Title: <br /> Received By: Date: <br />