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EWRONMENTAL.HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:vw✓w.sjgov.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address Eo <br /> I�J 6 W , JC 14�.t UTF L-0 1 ' _. ' P( r"P,.3 G 3S- 1nsp <br /> /0 16 /1 ve <br /> GommentsNeasurementsl U <br /> ParameterlStandard --F Meets SJG Standards? Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes © No ❑ INA❑ <br /> Casing extends at least 12" above grade Yes JQ No ❑ INA❑ <br /> Casing extends at least 1" above pedestal Yes No A NA❑ <br /> Free of cracks/contiguous with annular seal Yes ® No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes No ❑INA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing IYes 0 No ❑ INAF7 <br /> Seal between all pipe columns and casing Yes No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yes No ❑ NA ❑ <br /> Chlorination port available and sealed properly Yes lNo ❑ 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 [O No ❑ NA ❑ <br /> Adequately installed check valve or BFP device Yes No ❑ INA ❑ <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 Q <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes ® No ❑ NA❑ <br /> WeII/Pump free from excessive vegetation Yes FZI 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 ❑ lf'no'is selected, attach an accurate map to permit <br /> Photograph taken and attached to record Yest[7 No ❑ <br /> OTHER: <br /> C®mments: <br /> Y <br /> nspected By: Gth Sq Title: �' H- 3fii <br /> 'Zeceived By: Date: <br /> cu A,)nn <br />