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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.om/ehd <br />PUMP INSPECTION CHECK LIST <br />Address: <br />r • 1 � % lS � LST' <br />V <br />erm' ft 38 <br />POT <br />Ir�spegEio/r} D te: <br />V�L�[j rr V� <br />Parameter/Standard <br />Meets SJC Standards? <br />Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) <br />Yes Ej ' <br />No ❑ <br />NA ❑ <br />Casing extends at least 12" above grade <br />Yes [2' <br />No ❑ <br />NA ❑ <br />Casing extends at least 1" above pedestal <br />Yes D <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 />Yes <br />No ❑ <br />NA ❑ <br />Seal between all pipe columns and casing <br />Yes ['j <br />No ❑ <br />NA ❑ <br />Sounding tube/air vents sealed properly <br />Yes [2 <br />No ❑ <br />NA ❑ <br />Chlorination port available and sealed properly <br />Yes ❑ <br />No ❑ <br />NA M <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 Q" <br />Adequately installed check valve or BFP device <br />Yes Y <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 0 <br />No ❑ <br />NA []' <br />Air gap of at least 6" (same as pipe diameter) <br />Yes ❑ <br />No ❑ <br />NA [" <br />MAINTENANCE: <br />Well/Pump visible and protected from damage <br />Yes [0 <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 />No ❑ <br />If'no' is selected, attach an accurate map to permit <br />Permit drawing sufficient to locate well in future <br />Yes <br />No ❑ <br />Photograph taken and attached to record <br />Yes Q <br />No ❑ <br />OTHER: <br />Comments:: <br />l <br />Inspected B <br />p y: SQ <br />Title: - SdIJ <br />Received By: <br />Date: <br />cu n)nn n/v1ronir <br />