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s <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTI-I DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.slgov.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Permit#: Inspection Date: <br /> Coin inents/Measurements/ <br /> Parameter/Standard Meets SJC Standards? Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes 0 No ❑ NA ❑ <br /> Casing extends at least 12" above grade Yes �� No ❑ NA ❑ <br /> Casing extends at least 1" above pedestal Yes © No ❑ NA ❑ <br /> Free of cracks/contiguous with annular seal I�Yes No ❑ NA ❑Graded to allow drainage away from casing s No ❑ NA ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes [A No ❑ NA ❑ <br /> Seal between all pipe columns and casing Yes ✓ No [:1 NA ❑ <br /> Sounding tube/air vents sealed properly IYes ❑ . No ❑ NA [f <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 [VJ NA ❑ <br /> Adequately installed check valve or BFP device IYes No ❑ NA ❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from dcmestic supply) Yes ❑✓ No ❑ NA ❑ <br /> Air gap of at least 6:' (same as pipe diameter) Yes ❑ No ❑ NA <br /> t�l� <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes Ed' No ❑ NA ❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes V ,No ❑ <br /> Permit drawing sufficient to locate well in future Yes BINo ❑ if'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER: <br /> Comments: <br /> Inspected B _ <br /> Date: <br /> Title: <br /> Received By: <br />