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' 4 ' <br /> 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 /> Address: Perm!VA: Inspctio Date: <br /> c,f � R I Pv},l� GZD R P InJ e-o ���' © a 2,j oj� <br /> Parameter/Standard Meets SJC Standards? Commcomm ndati meats/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes M No ❑ INA ❑ <br /> Casing-extends at least 12" above grade Yes Ea No ❑ NA❑ <br /> Casing extends at least 1" above pedestal Yes No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes [2 No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes Q No ❑ NA ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes No ❑ NA❑ <br /> Seal between all pipe columns and casing Yes No ❑ NA❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑ NA 1vr <br /> Chlorination port available and sealed properly IYes 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❑ <br /> Adequately installed check valve or BFP device Yes No ❑ NA❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No ❑ NA <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA[� <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No ❑ INA ❑ <br /> Well/Pump free from excessive vegetation IYes No ❑ INA ❑ 1 - <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location,of well Yes Ej No ❑ <br /> Permit drawing sufficient to locate well in future Yes No ❑ If`no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes [Z No ❑ <br /> OTHER: — <br /> Comments: <br /> < n l <br /> Inspected By: s Title: Mt- Sl <br /> Received By: Date: <br />