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i <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 />Addre I PA-RA-NSL-{ K <br />Permi <br />1m 3� cJ1�� <br />/;Z1 J]a - <br />e �/ <br />Parameter/Standard <br />Meets SJC Standards? <br />Commentsimeasurements] <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes Y <br />Casing extends at least 12" above grade Yes ©' <br />Casing extends at least 1" above pedestal Yes 62 <br />ANoNA <br />Free of cracks/contiguous with•annular seal Yes Q <br />Graded to- allow drainage away from casing Yes ® <br />SANITARY SEAL: <br />Well is sealed between pump and casing <br />IYes U <br />❑ <br />Seal between all pipe columns and casing <br />Yes [� <br />K[O:j <br />❑ <br />Sounding tubefair vents sealed properly <br />Yes ❑[� <br />Chlorination port available and sealed properly <br />Yes <br />❑ <br />SAMPLE TAP AND BACKFLOW PREVENTION: <br />Non -threaded sample tap between well head and <br />check valve or within 3' of well head <br />Yes V <br />No ❑ <br />INAE] <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 />MAINTENANCE: <br />Well/Pump visible and protected from damage <br />Yes kZ <br />No ❑ <br />NA ❑ <br />Weil/Pump free from. excessive vegetation <br />Yes U <br />No ❑ <br />NA ❑ <br />(MISCELLANEOUS: <br />Permit drawing represents actual location of well <br />Permit drawing sufficient to locate well in future <br />Photograph taken and attached to record <br />OTHER: <br />Comments' <br />I <br />=1010 <br />W!Om <br />I/IM <br />If `no' is selected, attach an accurate map to permit <br />(Inspected By: l add I Q) ITitte: F 14 - ASsls Viu� ' I <br />[Received By: . I Date: <br />