Laserfiche WebLink
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.ora/ehd <br />PUMP INSPECTION CHECK LIST <br />Address: -- Few <br />0 49 W . VoSCm r� Pr vE LA T1�R p� w'oo 3 -) o 73 <br />Parameter/Sfandard Meets 5JC Standards? CommentsJMeasurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (21x2'x4" minimum) <br />Yes V No ❑ NA <br />Casing extends at least 12" above grade <br />Yes Q No ❑ NA <br />Casing extends at least V above pedestal <br />Yes No ❑ NA <br />Free of crackslcontiguous with annular seal <br />Yes j] No N;q <br />Graded to allow drainage away from casing <br />Yes Q' No ❑ INA <br />SANITARY SEAL: <br />Well is sealed between pump and casing <br />Yes VI No ❑ NA <br />Seal between all pipe columns and casing <br />Yes ® No ❑ NA [ <br />Sounding tubetairvents sealed properly <br />Yes ❑ No ❑ NA j <br />Chlorination port available and sealed properly <br />Yes j� No ❑ 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 Yes ❑ No W NA [ <br />Adequately installed check valve or BFP device <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic sup ly <br />IYesZ No ❑ I NAE <br />Yes ED] No L] NA <br />Air gap of at least 6" same as pipe diameter) <br />Yes ❑ No ❑ NA <br />MAINTENANCE: <br />Well/Pump visible and protected from damage <br />Yes No ❑ NA C <br />Well/Pump free from excessive vegetation <br />Yes No ❑ NA [ <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well <br />o [ <br />Permit drawing sufficient to locate well in future <br />jYesfNoE <br />o <br />Photograph taken and attached to record <br />OTHER: <br />C <br />If 'no' is selected, attach an accurate map to permit <br />CY 0, C,& -3 C144 C) sa-MrA k� <br />Inspected By: w4 Title: <br />Received By: d.Date: <br />=u n -.)nn <br />I <br />