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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.si oq v.or-g/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Addr ss: PEl erm" Tit <br /> fion ate:�10� N 1 ���-� LrJ S�c�"1 r.J o�3�� �� t <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 V above pedestal Yes No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes [,7( No ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes 6' No ❑ INA ❑ <br /> Seal between all pipe columns and casing Yes W No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑ NA[fir <br /> Chlorination port available and sealed properly 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 No ❑ NA ❑ <br /> Adequately installed check valve or BFP device Yes V1 No ❑ NA ❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No ❑ NA[j� <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA [r <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes Q' No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes g 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 /> Comments: C V-r.,L r4y qA,� <br /> --- - <br /> f <br /> i <br /> lnspecte�11,. OLI J V Title: �S <br /> Received By: Date: <br /> =u n,)nn <br /> sz112110na <br />