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S <br /> 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.sigov.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address- Perm��.� �� � � nspe�on late: <br /> E( <br /> L t jA-a r 01 R-J J( U l � 'V O <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 ❑ o (.e� CGS�.nr <br /> Casing extends at least 12" above grade Yes ❑ No ❑ NA ❑ <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 Yes [0 No ❑ NA ❑ <br /> Seal between all pipe columns and casing Yes 0 No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑ NA <br /> Chlorination port available and sealed properly Yes [2 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 YesE] No W NA ❑ <br /> Adequately installed check valve or BFP device Yes [2 No ❑ NA ❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) - Yes ❑ No ❑ NA D <br /> Air gap of at least 6" (same as pipe diameter) IYes ❑ INo ❑ NA <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes 2 No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes [2[ 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: r <br /> — 0a S� A-6y <br /> D c� t � <br /> Inspected By: 0L4, �SO Title: <br /> Received By: Date: <br /> EH-4200- 8/31/2015 <br />