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ENVIRONMENTAL HEALTH UEPARTMENT <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: �.l � P": <br /> � Lisp ti Dafie: <br /> �I � � � • ��Nn�� � P o V V C/�� <br /> Gomm encs/Measurements/ <br /> Parameter/Standard Meets S 1G Standards? Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) IYes [d No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes EZ No ❑ NA❑ <br /> Casing extends at least 1" above pedestal Yes [2 No ❑ NA❑ <br /> Free of crackstcontiguous with annular seal Yes F,� 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 2 No ❑ NA❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑ NA Z <br /> Chlorination port available and sealed properly Yes 2 No ❑ NA❑ <br /> SAMPLE TAP AND BACKFLOW PREVENTION: <br /> Non-threaded sample tap between well head and �S'a ,�, �• f� i„ <br /> check valve or within 3' of well head Yes ❑ No ® INA ❑ <br /> Adequately installed check valve or BFP device Yes Fz] No ❑ INA ❑ <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[g <br /> MAINTENANCE: <br /> We11/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 )2 No ❑ <br /> Permit drawing sufficient to locate well in future Yes 21 No ❑ If'no'is selected, attach an accurate map to permit <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER: <br /> Comments: e 4,2-�i <br /> I/1 <br /> hspected By: S "title: I'4 " r-43Jiyf c..!► <br /> :Zeceived By: Date: <br /> cu n�nn <br /> 5)/Q^Ion"� <br />