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671-iv VIJt'1L Will % vtUfv1 I <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.om/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: L Perm : <br /> Ins tion a A• <br /> J0 !V Els ra. <br /> ParameterlStandard Meets SJG Standards? Com ments/Meas urem encs/Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface sea] (2'x2'x4" minimum) Yes ® No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes Q' No ❑ NA❑ <br /> Casing extends at least 1u above pedestal Yes No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes Q No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes L� 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 tubelair vents sealed properly Yes FZ No ❑ NA ❑ <br /> Chlorination port available and sealed properly Yes V 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 E?�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 21 <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 ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes No ❑ <br /> Permit drawing sufficient to locate well in future Yes No ❑j If'no'is selected, attach an accurate map to permit <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER: <br /> �jomment <br /> Inspected By: O.So Title: A�St.1 <br /> Received By: Date: <br /> r=u nonn n/v�lin t <br />