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r 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.s'Igov.orq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Per i : insp�cti'D�D te: <br /> I a L 8 E- v �u� Esc.gCo� l,.` yftno 8 <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4' minimum) Yes ® No ❑ F0--] <br /> Casing extends at least 12" above grade Yes 0 No ❑Casing extends at least 1 uabove pedestal Yes © No ❑Free of cracks/contiguous with annular seal Yes © No ❑Graded to allow drainage away from casing Yes [✓] No ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes [ih No ❑ NA❑ <br /> Seal between all pipe columns and casing Yes Q No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yes W No ❑ NA❑ <br /> Chlorination port available and sealed properly Yes W] 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 Q No ❑ NA ❑ <br /> Adequately installed check valve or BFP device Yes V 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 /> WeIUPump visible and protected from damage Yes L2 No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes Q No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes 2 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 No ❑ <br /> OTHER: <br /> Comments: <br /> Inspected By: ��ll Title: - S <br /> Received By: Date: <br /> Cu nonn <br /> ni144 ion4 c <br />