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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.sigov.orq/ehd <br />PUMP INSPECTION CHECK LIST <br />Address nn �� JJ3'75'71^ <br />ills E gj) S/ 0 �/" <br />ParameterlStandard Meets SJC Standards? <br />p�%�o 0� SPIdoZn late: <br />Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) <br />YeOF] <br />Casing extends at least 12" above grade <br />YeCasing <br />extends at least 1" above pedestal <br />YeFree <br />of cracks/contiguous with -annular seal <br />YesGraded <br />to -allow drainage away from casing <br />Yes <br />SANITARY SEAL: <br />Well is sealed between pump and casing <br />Yes ® No ❑ <br />NA ❑ <br />- <br />Seal between all pipe columns and casing <br />Yes W No ❑ <br />NA F] <br />Sounding tubefair vents sealed properly <br />Yes ❑ No ❑ <br />NAM <br />Chlorination port available and sealed properly <br />Yes No ❑ <br />NA ❑ <br />SAMPLE TAP AND DAGKFLOW PREVENTION: <br />Non -threaded sample tap between well head and <br />check valve or within 3' of well head <br />Yes <br />No ❑ <br />NA ❑ <br />Adequately installed check valve or BFP device <br />Yes <br />No ❑ <br />NA ❑ <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) <br />Yes ❑ <br />No ❑ <br />NA <br />Air gap of at least 6" (same as pipe diameter) <br />Yes ❑ <br />No ❑ <br />NA <br />