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t <br /> 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:www.sigov.org/ehd <br /> PUMP INSPECTION CHECKLIST <br /> Address: aroo <br /> Inspe ion Date: <br /> 0 C� 0 E - LO Q Mb '�� L 1 /\1b 34? ©N -I 0s3o/l <br /> Pararneter/Standard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes ®' No ❑ NA ❑ <br /> Casing extends at least 12" above grade Yes Q° No ❑ NA ❑ <br /> Casing extends at least 1" above pedestal _Yesp No ❑ NA ❑ <br /> Free of cracks/contiguous with annular seal Yes (2 No ❑ NA ❑ <br /> Graded to allow drainage away from casing Yes [9 No ❑ NA ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes ❑^ No ❑ INA❑ <br /> Seal between all pipe columns and casing Yes ER' No ❑ NA ❑1 <br /> Sounding tube/air vents sealed properly Yes ❑/ No ❑ NA❑ <br /> Chlorination port available and sealed properly I Yes ❑ 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 JZ No ❑ NA ❑ <br /> Adequately installed check valve or BFP device Yes L?f No ❑ NA ❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes El No ❑ NA&. <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA Z <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes kZ No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes VF 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 ❑ if'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER: <br /> Coram t�: <br /> Inspected By: TQA-AJ a Title: <br /> Received By: Date: <br /> FN_a,)nn_ 8/3112015 <br />