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ENVIRONMENTAL HEALTH DEPARTMENT <br /> 9 868 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: Permi recti n Date: <br /> IS <br /> u rem ends/ <br /> Parameter/Standard Meets SJG Standards? Com ments/MeasRecommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes fo No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes 12 No ❑ NA❑ <br /> Casing extends at least 1u above pedestal Yes [2 No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes ® No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes [0 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 PFDperly Yes L] No ❑ NAV <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 V lNo ❑ INA❑ <br /> Adequately installed check valve or BFP device Yes V I 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 <br /> MAINTENANCE: <br /> WelVPump visible and protected from damage Yes 12 No ❑ NA❑ <br /> WeIUPump free from excessive vegetation Yes Z� No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes No ❑ <br /> Permit drawing sufficient to locate well in future Yes [2 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 /> 4-ey <br /> nspecfed By: J Title: (� A.sf! ! <br /> deceived By: Date: <br /> �u inn <br />