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n <br /> Y SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 9 868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209)468-3420 Fax: (209) 468-3433 Web;www.s' ov.or /ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address, r ( �:L Inspection Date: <br /> Q �O <br /> ParameterlStandard Meets SJLStan�d�ards±? 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 YesE41 No ❑ NA❑ <br /> Casing extends at least 1u above pedestal Yes [j No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes Q 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 No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yes [, f No ❑ INA <br /> Chlorination port available and sealed properly Yes 4 No ❑ NA❑ <br /> SAMPLE TAP AND BACKFLOW PREVENTION: <br /> Non-threaded sample tap between well head and - ! -- <br /> check valve or wi [�thin 3' of well head Yes No ❑ NA ❑ <br /> Adequately installed check valve or BFP device Yes [Q No ❑ NA❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes [x 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 Yes No ❑ NA❑ <br /> Well[Pump free from excessive vegetation Yes [t No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes f j 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 /> Comments: <br /> Inspected By: Tide: St <br /> I <br /> Received I3y: Date: <br /> =u n'nn <br />