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ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.sigov.Drq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address; Pe Insp�fiion : <br /> Parameter/Standard Meets SJG Standards? Com ments/Meas u rem encs!ReGommendat:ions <br /> GEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes No ❑ NA❑ <br /> Casing extends at Ieast 12" above grade Yes &6 No ❑ NA❑ <br /> Casing extends at least 1" above pedestal Yes fV� No ❑ NA❑ <br /> Free of crackstcontiguous with annular seal Yes No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes JZ No ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes No ❑ INA❑ <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 V No ❑ NA ❑ <br /> Adequately installed check valve or BFP device Yes V No ❑ NA ❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No ❑ NA JZ <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ INA IV <br /> MAINTENANCE: <br /> WeIVPump visible and protected from damage Yes 2 No ❑ NA❑ <br /> WeII/Pump free from excessive vegetation Yes j No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well IYes [] 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 Yes © No ❑ <br /> DTHER: <br /> Comments: <br /> :nspected By: b Title � ISI,( �' <br /> ,eceived By: Date: <br /> 1--u nonn <br /> na r- <br />