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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95206-6232 <br /> Telephone:(209)468-3420 Fax. (209)468-3433 Web:www.sjgov.orq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: �3 ; 'SP C-,ss n _ �u PeWP00,3r S'/� C-1 . io %ate: <br /> I ( j'1 �/ Comm1entslMeasurernen/s/ <br /> Parameter/Standard Meets AJC Standards? Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes L2 No ❑ NA ❑ <br /> Casing extends at least 12" above grade Yes ®' No ❑ NA ❑ <br /> Casing extends at least 1" above pedestal Yes © No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes ® No ❑ NA❑ ` <br /> Graded to allow drainage away from casing Yes V 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 ❑ NAD' <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑ NAM <br /> Chlorination port available and sealed properly Yes 2 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 [V NA❑ <br /> Adequately installed check valve or BFP device Yes 0 No ❑ NA❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No ❑ NA M <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA Rr <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location• of well Yes 0 No ❑ <br /> Permit drawing sufficient to locate well in future Yes No Ellf'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes [✓]� No ❑ <br /> OTHER: <br /> Comments: <br /> Inspected By: o" Oso Title: l 3 <br /> Received By: Date: <br /> Fu_n,)nn- 8/31/2015 <br />