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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East HazeIton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: wvvvv.sjoov.orq/ehd <br />PUMP INSPECTION CHECK LIST <br />Address: <br />5-"O. //s7„ d_ <br />Permit#: <br />.-i_re2 7 7 6/2 <br />Inspgction Date: <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes p No LI NA LI <br />Casing extends at least 12" above grade Yes H No LI NA LI <br />Casing extends at least 1" above pedestal Yes LI No Fl NA LI <br />Free of cracks/contiguous with annular seal Yes El No LI NA LI <br />Graded to allow drainage away from casing Yes ill No LI NA n <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes No 11 NA LI <br />Seal between all pipe columns and casing Yes 17 No ri NA LI <br />Sounding tube/air vents sealed properly Yes LI No LI NA F <br />Chlorination port available and sealed properly Yes El No LI NA n <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 LI No (A NA LI <br />Adequately installed check valve or BFP device Yes IT No NA LI <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes LI No LI NA E. <br />Air gap of at least 6" (same as pipe diameter) Yes n No NA [— <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes Fl No LI NA I I <br />Well/Pump free from excessive vegetation Yes 71 No LI NA LI <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes p_. No I 1 <br />If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes No LI <br />Photograph taken and attached to record Yes I- No 1 I <br />OTHER <br />Com ents: <br />Inspected By: -I- 7---- Title: <br />Received By: Date: <br />SQ/-1 fOrlig