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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:wwvv.sigov.orgtehd <br /> PUMP INSPECTION CHECKLIST <br /> Address: <br /> a ped#-a /' p�� Ins nI; f <br /> b o <br /> Parameter/Standard Meets SJG Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimuWW� l <br /> NA❑ <br /> Casing extends at least 12"above gradeNA❑ <br /> Casing extends at least V above pedestalNA❑ <br /> Free of cracks/contiguous with annular sealA❑ Ofi,uv Lr ko <br /> Graded to allow drainage away from casingA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes VWEDIN <br /> Seal between all pipe columns and casing Yes <br /> Sounding tube/air vents sealed properly Yes ❑ <br /> Chlorination port available and sealed pro erly Yes JZ <br /> SAMPLE TAP AND BACKFLOW PREVENTION: <br /> Non-threaded sample tap between well head and ,S <br /> check valve or within 3' of well head Yes❑ Nog NA❑ <br /> Adequately installed check valve or BFP device Yes W No ❑ NA❑ <br /> No cross connectibns (ex: chemical feeders <br /> hooked to distribution systern/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 /> Well/Pump visible and protected from damage YesV No ❑ NA❑ <br /> VVelllPump free from excessive vegetation Yes No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yesff <br /> Permit drawing sufficient to locate well in future Yes 'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes } <br /> OTHER: <br /> Comments: <br /> Inspected By: So - Title:�'IVl rb h �a( h•e-alfa �}-�`s� ,,� <br /> Received By; Date; <br /> cu n-nn <br />