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SAN.JOAQUIN COUNTY <br /> P 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: Pe 't#: Insp do Date: <br /> q0 X �-10J 8 o418 <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal 2'x2'x4" minimum Yes ❑ Nog NA❑ Dt l ki �-. xa <br /> Casing extends at least 12" above grade Yes V No ❑ NA❑ <br /> Casing extends at least 1" above pedestal Yes ❑ No V1 NA❑ n,wt v <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 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 [:1 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 ElNo NA E] 'S <br /> 4s <br /> Adequately installed check valve or BFP device Yes jZ No ❑ NA❑ <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(Z <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes W]j No ❑ I 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 [A No ❑ <br /> OTHER: <br /> Comments: <br /> C'r c'- 1Wt a' X'9' <br /> Cis Pzj-W -� <br /> ------------- <br /> Inspected By: Cl h Title: <br /> Received By: Date: <br /> Mu A'3nn <br />