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r r x SAN JOAQUIN COUNTY 1 <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.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Pe InsH?! Date: <br /> v A)Q PJ �S(-AbA ` v3BParameter/standard Meets SJC Standards? Comments/Measureme <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) I Yes ® I No ❑ INA❑ <br /> Casing extends at least 12" above grade Yes R1 FNo ❑ NA ❑ <br /> Casing extends at least 1° above pedestal Yes Q No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes © No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes �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 [ZNo ❑ NA❑ <br /> Chlorination port available and sealed properly Yes 0 No ❑ INA.0 <br /> SAMPLE TAP AND BACKFLOW PREVENTION: <br /> Non-threaded sample tap between well head and <br /> check valve or within T of well head Yes Ej 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❑ NAIZ <br /> Air gap of at least 6" same as pipe diameter Yes ❑ No❑ NA <br /> MAINTENANCE: <br /> VVell/Purnp visible and protected from damage Yes No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes Z 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: <br /> Received By: Date: <br /> cu aI)nn <br /> av�imine c <br />