Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 96205-6232 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.slgov.orq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Permi : Inspe tion te: <br /> ao S, c�)� R ►� ;TkAC od 3 2 68 <br /> Parameter/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 ❑ No ❑ NA❑ <br /> Casing extends at least 1° above pedestal Yes ❑ No ❑ NA❑ Nb ea <br /> Free of cracks/contiguous with annular seal Yes ❑ 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 ❑ INA❑ <br /> Seal between all pipe columns and casing Yes ❑i/ No ❑ INA❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑ NA[2 p <br /> Chlorination port available and sealed properly Yes W lNo ❑INA❑ <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 ❑ No V NA ❑ b Sr.4q Xy+ t <br /> Adequately installed check valve or BFP device Yeso No ❑ NA❑ <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[2 <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes L2 No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes 2r 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`ne is selected, attach an accurate map to permit <br /> Photograph taken and attached to record Yes ® No ❑ <br /> OTHER: <br /> Comments: <br /> Inspected By: CL4 Sd Title: ISS. <br /> Received By Date: <br /> CLI An- <br />