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f <br /> r 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.orq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address q 6 ! w. �C� � C Per o O 39� I��Gtgat,: <br /> !�7 (076? <br /> Com ments/Measurements/ <br /> Parameter/Standard Meets SJC Standards? Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes [jA No ❑ NA ❑ <br /> Casing extends at least 12" above grade Yes [2 No ❑ NA ❑ <br /> Casing extends at least 1" above pedestal Yes ❑ No Ek NA❑ Cai�, CI <br /> Free of cracks/contiguous with annular seal Yes 0 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 9 No ❑ NA❑ <br /> Seal between all pipe columns and casing Yes U No ❑ NA❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑ NA EV <br /> Chlorination port available and sealed properly Yes V No ❑ NA ❑ <br /> SAMPLE TAP AND BACKFLOW PREVENTION: <br /> Non-threaded sample tap between well head and fly. <br /> check valve or within 3' of well head Yes ❑ No NA El <br /> Adequately installed check valve or BFP device Yes ❑ No NA ❑ rf ` <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ o ❑ NA <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑jNo ❑ NA [Z <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes Rj No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes [ 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: <br /> P) Ouvt Le . <br /> Inspected By: CV., `S Title: <br /> Received By: Date: <br /> FN_a?nn_ 8/,91/2015 <br />