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• SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 9868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Ea r:(209)468-3433 Web:www.sigov.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Perm� Z�'� In a <br /> Address: � <br /> CommentslMeasuremen <br /> Parameter/Standard Meets SJC Standards? Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal 2'x2'x4" minimum) Yes No ❑ NA❑ <br /> Casing extends at least 92" above grade Yes 't] No❑ NA❑ <br /> Casing extends at least 9" above pedestal Yes No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes© No❑ NA❑ <br /> Graded to allow drainage awayfrom casing Yes R] No ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between um and casing Yes� No ❑ NA❑ <br /> Seal between all pipe columns and casin Yes No❑ NA❑ <br /> Sounding tubelair vents sealed property Yes❑ No❑ NA(� <br /> Chlorination ort available and sealed properlyYes ( 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® tNA <br /> Adequately installed check valve or BFP device Yes <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution systemlag flood irrigation Yes❑from domestic supply)Air gap of at least 6' (same as i e diameter) Yes❑ <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes ® No F1 NA❑- -- <br /> Well/Pump free from excessive vegetation Yes f] No ❑ NA❑ ------ - <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes No ❑ <br /> Permit drawing sufficient to locate well in future <br /> Yes No F] lf'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes ❑ No M <br /> OTHER: - <br /> Comments:/i,*yVs�r <br /> Ins ected B : <br /> Date: <br /> Received By: <br /> ` n.na annar <br />