Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTMENT <br />9868 East Hazelton Avenue, Stockton, CA 96206-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.orq/ehd <br />PUMP INSPECTION CHECK LIST <br />Address: Pe <br />a q m(I1>z � RJ I Po r.,j' oo3'7q r7 <br />fns�T;r-tir Date: <br />io <br />ParameterlStandard <br />Meets SJG Standards? Com m ents/Measu rem encs/Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) <br />IYes ® <br />1 No ❑ <br />I NA ❑ <br />Casing extends at least 12" above grade <br />I Yes [V <br />INcEl <br />JNAFJ <br />Casing extends at least 1" above pedestal <br />Yesir <br />No [0 <br />INA ❑ <br />CW,;, o al e to <br />Free of cracks/contiguous with annular seal <br />Yes ✓❑ <br />No ❑ <br />NA ❑ <br />Graded to allow drainage away from casing <br />Yes <br />lNo ❑ <br />NA ❑ <br />SANITARY SEAL: <br />Well is sealed between pump and casing <br />IYes V <br />INo ❑ <br />NA ❑ <br />Seal between all pipe columns and casing <br />Yes FJI <br />No ❑ <br />NA ❑ <br />Sounding tube/air vents sealed properly <br />Yes ❑ <br />No ❑NA <br />2 <br />Chlorination port available and sealed properly <br />Yes V <br />Nc ❑ <br />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 <br />Yes T <br />lNoEl �NA <br />❑ <br />Adequately installed check valve or BFP device <br />Yes M <br />No ❑ INA <br />❑ <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) <br />Yes ❑ <br />No ❑ <br />NA [ <br />Air gap of at least 6" (same as pipe diameter) <br />Yes ❑ <br />No ❑ <br />NA <br />[MAINTENANCE: <br />Well/Pump visible and protected from damage I <br />Yes [a INo <br />❑ <br />NA ❑ <br />Well/Pump free from excessive vegetation IYes <br />L <br />No ❑ <br />NA ❑ <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well <br />Yes ® <br />No ❑ <br />if `no' is selected, attach an accurate map to permit <br />Permit drawing sufficient to locate well in future <br />Yes <br />No ❑ <br />Photograph taken and attached to record <br />Yes <br />No ❑ <br />OTHER: <br />C®mments: <br />�Tin /r1J }4 ��d (.Q ►mss .�� s�►.P <br />nspected By: Out, S a <br />Title: - A-G!J <br />,eceived By: <br />Date: <br />7:u n'�nn <br />nIa.1r1)n.1 �- <br />