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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 /> Addresss- -I {� /� p -'} *� <br /> 0 t CA ream' EfCAto PW '6 03 l vC o - ]!spebion ate: <br /> ParameterlStandard Meets SJC Standards? Comments/Measurements <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4' minimum) 1YesE1 !No <br /> %NA <br /> - <br /> Casing extends at least 12" above grade Yes ❑ �. � <br /> Casing extends at least V above pedestal Yes ❑ ,Y <br /> Free of crackslcontiguous with-annular seal Yes ❑ <br /> Graded to-allow drainage away from casing Yes ❑ <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 tubefairvents sealed properly Yes ❑ No ❑ NA[� <br /> Chlorination port available and sealed properly Yes [ 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 ❑ 1 <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 Ieast 6" (same as pipe diameter) Yes ❑ No ❑ NA M <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No ❑ NA❑ <br /> Well/Pump free from.excessive vegetation Yes Kj No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes No❑ <br /> Permit drawing sufficient to locate well in future YesD No ❑ lf'nd is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER: <br /> Comments <br /> Ce 4 <br /> Inspected By: CLA-. J� Titie: — <br /> Received By: pate: <br />