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I 1 0 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />TeIephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.orq/ehd <br />PUMP INSPECTION CHECK LIST <br />aaaress: (� / rt r�C�'e Perini / <br />`3 (� L, V /V �S' C �- �0 I�% i0 p ale: <br />F <br />Parameter/Standard Meets 5JC standards? Comments/Measuremen•ts1 <br />CEMENT PEDESTAL: <br />Dimensions of surface seal 2'x2'x4" minimum) <br />jYes & INo ❑ INA [ <br />Casing extends at least 12" above grade <br />IYes No ❑ INA [ <br />Casing extends at least 1" above pedestal <br />Yes J�4 INo ❑ I NA [ <br />Free of cracks/contiguous with annular seal <br />IYesEllNoF]NA[ <br />Graded to allow drainage away from casing <br />Yes No ❑ NAE <br />SANITARY SEAL: <br />NA ❑ <br />Well is sealed between pump and casing <br />Yes No ❑ NA ❑ <br />Seal between all pipe columns and casing <br />Yes Q No ❑ NA ❑ <br />Sounding tubelair vents sealed properly <br />Yes No ❑ NA ❑ <br />Chlorination port available and sealed properly <br />Yes ❑ No NA ❑ <br />SAMPLE TAP AND BACKFLOW PREVENTION: <br />OTHER: <br />Non -threaded sample tap between well head and <br />check valve or within 3' of well head <br />Yes ❑ No NA ❑ <br />Adequately installed check valve or BFP device <br />Yes No ❑ NA ❑ <br />No cross connections (ex: chemical feeders <br />hooked to distribution systemlag flood irrigation <br />from domestic �i inniv) <br />V-- hl- r-1 Rin r. <br />Recommendations <br />of at least &'(same as pipe diameter)ENANCE: <br />fAirgap <br />mp visible and protected from damage <br />Yes <br />No ❑ <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 />Yes <br />Yes <br />VNolf-'no'lsselected, attach an accurate map to permit <br />Permit drawing sufficient to locate well in future <br />Photograph taken and attached to record <br />OTHER: <br />Comments: <br />/ I W ` - q v � • V L V— 1'y -r' rr^I % <br />t <br />«1-z'NeL:Leu ny: I V-Ao�. I f v IV <br />Received By: pate: <br />cu A,;,nn <br />