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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.sjgov.=/ehd <br /> PUMP INSPECTION CHECK L.I,�T p <br /> Address: 6�. 1 T W c� I V �0 l y PW�vcv7? 6 O ?v Insp1,/ )ate: <br /> CommentslMeasurements!// <br /> Parameter/Standard Meets SJC Standards? Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes No ❑ NA ❑ <br /> Casing-extends at least 12' above grade Yes [0 No ❑ NA❑ <br /> Casing extends at least 1" 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 D No ❑ NA ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes Q No ❑ NA ❑ <br /> Seal between all pipe columns and casing Yes 0 No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yes [0 No ❑ NA ❑ <br /> Chlorination port available and sealed properly Yes [jX 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 ❑ NA 9 <br /> Adequately installed check valve or BFP device Yes a No ❑ NA❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) I Yes ❑ No ❑ NA[� <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA[Z <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes R I No ❑ NA ❑ <br /> MISCELLANEOUS: -- <br /> Permit drawing represents actual location.of well YesEj, No ❑ <br /> Permit drawing sufficient to locate well in future Yes [2 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: <br /> Title: A 1S <br /> Received By: Date: <br /> ' 1 <br /> I <br />