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Y SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> " <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.sigov.org/ehd <br /> PUMP INSPECTION CHECK IST <br /> Address: 5 3 Cc��E�k peG�'ction Dat� �D C�� N o© vu 3/ I ?e: <br /> Parameter/Standard Meets SJC Standards? F 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 T No ❑ NA❑ •vc C <br /> Casing extends at least 1" 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 ❑ No ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing IYes 0 No ❑ NA❑ <br /> Seal between all pipe columns and casing Yes 0 No ❑ NA ❑ <br /> Sounding tubelair vents sealed properly Yes ❑ No ❑ NA[q <br /> Chlorination port available and sealed properly Yes L 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 L4 No ❑ NA ❑ <br /> Adequately installed check valve or BFP device Yes ❑ 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 EY <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes 0 No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well 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 (Z No ❑ <br /> OTHER: <br /> Comments: <br /> Inspected By: c4u — Title: SSjS <br /> Received By: Date: <br /> cu n�nn <br /> ai,.iamneg <br />