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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.sigoy.orq/ehd <br />PUMP INSPECTION CHECK LIST <br />Address: <br />Q <br />_, '� S W U E R� C C Il <br />p <br />s F,() "?� 6oa <br />Inspecti on Date: <br />a/aJ r� <br />Parameter/Standard <br />Meets SJC Standards? <br />Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4u minimum) <br />Yes W <br />No ❑ <br />NA ❑ <br />Casing extends at least 12" above grade <br />Yes [0 <br />No ❑ <br />NA ❑ <br />Casing extends at least 1" above pedestal <br />Yes 7 <br />No ❑ <br />NA ❑ <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 />No ❑ <br />NA ❑ <br />SANITARY SEAL: <br />Well is sealed between pump and casing <br />Yes <br />No ❑ <br />NA ❑ <br />Seal between all pipe columns and casing —YesU <br />No ❑ <br />NA ❑ <br />Sounding tube/air vents sealed properly <br />Yes ❑ <br />No ❑ <br />NA FIA <br />Chlorination port available and sealed properly <br />Yes &A <br />No ❑ <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 91 <br />No ❑ <br />NA ❑ <br />; <br />Adequately installed check valve or BFP device <br />Yes 51 <br />No ❑ <br />NA ❑ <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 EZ <br />Air gap of at least 6" (same as pipe diameter) <br />Yes ❑ <br />No ❑ <br />NA <br />F:u n)nn <br />