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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.si ov.org/ehd <br />PUMP INSPECTION CHECK LIST <br />Address:/ .� <br />' 1 �-�- i I'vt A L L � .Si�x.�ib�./ <br />Parameter/Standard Meets SJC Standards? <br />Permi � Inspection Date: <br />o �8 <br />Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) <br />Yes Q <br />1 No ❑ <br />NA ❑ <br />Casing extends at least 12" above grade <br />Yes U <br />No ❑ <br />NA ❑ <br />Casing extends at least 1" 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 Q] <br />No ❑ <br />NA ❑ <br />SANITARY SEAL: <br />Well is sealed between pump and casing <br />IYes U <br />No ❑ <br />NA ❑ <br />Seal between all pipe columns and casing <br />Yes Y <br />No ❑ <br />NA ElSounding <br />tube/air vents sealed properly <br />Yes ElNo <br />❑ <br />NA 12,Chlorination <br />port available and sealed properly <br />Yes <br />No ❑ <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 <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 />C:u n)nn <br />nna i�na G <br />