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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.sigov.orq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> {address: <br /> - ���� / (& �( V�� O/j Pe� 0030,53 rmi Inspe tion ate: <br /> ParameterlStandard Meets SJC Standards? CommentslMeasuremen / <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes Q No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes © No ❑ NA ❑ <br /> Casing extends at least 1" above pedestal Yes 0 No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes ❑ No [Z NA❑ <br /> Graded to allow drainage away from casing Yes No ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing IYes © No ❑ NA❑ <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 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 No ❑ NA ED <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ElNo [:1NA <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No E01 NA <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes 2 No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes PT 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: d <br /> C.csti..L r� ��✓7v d``� ��� cJ"t ll <br /> Inspected By: OL,4 �� Title: <br /> Received By: Date: <br /> Cu n�nn <br />