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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.siaov.or. /q ehd <br /> PUMP INSPECTION CHECK LIST r <br /> Address: Perm't#: Ins ection Date: <br /> Q j Ll nJPcr� 003 qb to <br /> Para meterlStandard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes [9' No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes W No ❑ NA❑ <br /> Casing extends at least V 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 Of No ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes 9 No ❑ NA❑ <br /> Seal between all pipe columns and casing Yes U No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑ NA[v� <br /> Chlorination port available and sealed properly IYes ❑ No ❑ NA(Z <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 91 <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 IV <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA W <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes LZ No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes &4 No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes Q(' No ❑ <br /> Permit drawing sufficient to locate well in future Yes No ❑ If'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER: <br /> Comments: <br /> Inspected By: It 0'A". S -Title: Vl <br /> Received By: Date: <br /> C:u n'Dnn <br />