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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.sigov.orq/ehd <br />PUMP INSPECTION CHECK LIST <br />■ JJ <br />MAIN I CIVHN1-r =: <br />Well/Pump visible and protected from damage FY <br />Well/Pump free from excessive vegetation <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well <br />Permit drawing sufficient to locate well in future <br />Photograph taken and attached to record <br />OTHER: <br />C t• <br />No HNA <br />No F-1 INA <br />Yes No [-]Yes [2 No ❑ If'no' is selected, attach an accurate map to permit <br />Yes Non <br />ommen s. <br />4gtv "J✓ inl <br />ln/Qit..L U� OLJ 4"v'�h i n <br />��-�-��" �1. c✓� Dei 6 `7� <br />Inspected By: 1 0,1 ` N.,�> U I Title: & V I re t. rnu Q 4-eC 1ff- &) <br />Received By: Date: <br />r -u n -)nn <br />Perm i <br />o <br />In ction Date: <br />la z <br />Parameter/Standard <br />Meets SJC Standards? Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) <br />IYes 2 <br />No <br />Casing extends at least '12" above grade <br />Yes © <br />No <br />ANA <br />Casing extends at least 1" above pedestal <br />Yes © <br />NoFree <br />of cracks/contiguous with annular seal <br />Yes © <br />No <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 />IYes V <br />I NoJENA <br />Seal between all pipe columns and casing <br />Yes <br />No <br />Sounding tube/air vents sealed properly <br />Yes ❑ <br />NoChlorination <br />RO <br />port available and sealed properly <br />Yes <br />No <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 />jNoFj <br />NA ❑ <br />Adequately installed check valve or BFP device <br />IYes <br />No ❑ <br />NA ❑ <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) <br />1YesE] <br />No ❑ <br />NA <br />Air gap of at least 6" (same as pipe diameter) <br />Yes ❑ <br />No ❑ <br />NAVI <br />MAIN I CIVHN1-r =: <br />Well/Pump visible and protected from damage FY <br />Well/Pump free from excessive vegetation <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well <br />Permit drawing sufficient to locate well in future <br />Photograph taken and attached to record <br />OTHER: <br />C t• <br />No HNA <br />No F-1 INA <br />Yes No [-]Yes [2 No ❑ If'no' is selected, attach an accurate map to permit <br />Yes Non <br />ommen s. <br />4gtv "J✓ inl <br />ln/Qit..L U� OLJ 4"v'�h i n <br />��-�-��" �1. c✓� Dei 6 `7� <br />Inspected By: 1 0,1 ` N.,�> U I Title: & V I re t. rnu Q 4-eC 1ff- &) <br />Received By: Date: <br />r -u n -)nn <br />