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f , r <br /> 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.sigov.org/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 ❑ No ❑ INA❑ <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 Yes ❑ No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes ❑ No ❑ NA ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and Gasinq Yes ❑ No ❑ INA❑ <br /> Seal between all pipe columns and casing Yes ❑ No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑ NA❑ <br /> Chlorination port available and sealed properly Yes ❑ No ❑ I 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 ❑ 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 ❑ INA ❑ <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage INes ❑ No ❑ NA❑ <br /> Well/Pump free from excessive vegetation I Yes ❑ INoE1 INA ❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes [:11 No ❑ <br /> Permit drawing sufficient to locate well in future Yes ❑ 1 No ❑ I If'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes ❑ IND ❑ <br /> OTHER: <br /> Comments: <br /> Inspected By: Title: <br /> Received By: Date: <br /> Fu_ngnn_ 8/31/2015 <br />