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SAN JOAQUIN COUNTY <br />• ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95206-6232 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.s►clov.orq/ehd <br />PUMP INSPECTION CHECK LIST <br />Address:C LV, /�� Lb PaA' h( ^ <br />Parameter/Standard <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) <br />Yes <br />Casing extends at least 12" above grade <br />Yes <br />Casing extends at least 1" above pedestal <br />Yes <br />Free of cracks/contiguous with annular seal <br />Yes <br />Graded to allow drainage away from casing <br />Yes <br />SANITARY SEAL: <br />Well is sealed between pump and casing <br />Yes <br />Seal between all pipe columns and casing <br />Yes <br />Sounding tube/air vents sealed properly <br />Yes <br />Chlorination port available and sealed properly <br />Yes <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 <br />Adequately installed check valve or BFP device <br />Yes <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) <br />Yes <br />Air gap of at least 6" (same as pipe diameter) <br />Yes <br />MAINTENANCE: <br />Well/Pump visible and protected from damage ]yYes <br />Well/Pump free from excessive vegetation <br />Yes <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well <br />Permit drawing sufficient to locate well in future <br />Photooraoh taken and attached to record <br />OTHER: <br />Comments: <br />VVIS <br />P <br />Inspected By: <br />Received By: <br />rt -r -A CV Pty%` e -o3$ 2 � 8 l0 %3 i8 <br />Meets SJC Standards? Comments/Measurements/ <br />Recommendations <br />2■��■�■ <br />=ME <br />■ <br />=ME <br />=ME <br />ZME11■■ <br />No F-1 NA <br />No El NA❑ <br />No INAS' <br />No El INAM' <br />No INAU <br />No ❑ INA ❑ <br />Yes INo Lj <br />Yes No ❑ lf'no' is selected, attach an accurate map to permit <br />Yes No I-1 <br />Title: l•. " <br />Date: <br />Eu n'�nn <br />ot,�4 imine r <br />W, <br />