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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 />Title: It o 4. A -S5(13 <br />Date: <br />Cu nnnn <br />Address:_ _ <br />W fl RG 6n/ 1 (� l <br />eon Date:Paramee/Standard <br />PFJ 0 0 3-7 6 6 4-li 1.12-10WI-1 <br />Comments/Measurerents/ <br />Recommendations <br />Meets SJC Standards? <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) <br />Yes <br />No ❑ <br />NA El <br />Casing extends at least 12" above grade <br />Yes <br />No ❑ <br />NA ❑ <br />Casing extends at least V above pedestal <br />Yes <br />No ❑ <br />NA ❑ <br />Free of cracks/contiguous with annular seal <br />Yes <br />No ❑ <br />NA ❑ <br />Graded to allow drainage away from casing <br />Yes <br />No ❑ <br />NA ❑ <br />SANITARY SEAL: <br />Well is sealed between pump and casing <br />IYes Q <br />No ❑ <br />INA ❑ <br />Seal between all pipe columns and casing <br />Yes <br />No ❑ <br />INA E]Sounding <br />tube/air vents sealed properly <br />Yes ❑ <br />No ❑ <br />NA [V <br />Chlorination port available and sealed properly <br />Yes LZ <br />lNo ❑ <br />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 <br />Yes W <br />No ❑ <br />NA ❑ <br />Adequately installed check valve or BFP device <br />Yes 2( <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 />- <br />Air gap of at least 6" (same as pipe diameter) <br />Yes ❑ <br />No ❑ <br />NA FZ <br />MAINTENANCE: <br />Well/Pump visible and protected from damage <br />Yes ®No <br />❑ <br />NA ❑ <br />Well/Pump free from excessive vegetation <br />Yes [� <br />No ❑ <br />NA ❑ <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well <br />Yes] <br />No ❑ <br />`no' is selected, attach an accurate map to permit <br />Permit drawing sufficient to locate well in future <br />Yes <br />No ❑ If <br />Photograph taken and attached to record <br />Yes 0 <br />No ❑ <br />OTHER: <br />Comments: ! - <br />Title: It o 4. A -S5(13 <br />Date: <br />Cu nnnn <br />