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Y SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 96205-6232 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.s]gov.orq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: WA Z�r f �ZN0�1J q`�Z �b Permit#: Inspection Date: <br /> 00 3 "7C <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> GEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes Ej No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes U No ❑ NA❑ <br /> Casing extends at least 1° above pedestal Yes[I No ❑ NA❑ <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 [I No ❑ I NA❑ <br /> Seal between all pipe columns and casing Yes E4 No ❑ INA ❑ <br /> Sounding tube/air vents sealed properly Yes No ❑ NA❑ <br /> Chlorination port available and sealed properly IYes ❑ 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❑ <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❑ <br /> MAINTENANCE: <br /> VVe]VPump visible and protected from damage Yes No ❑ NA❑ <br /> We11/Pump free from excessive vegetation Yes 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: <br /> Inspected By= �,.� �� Title: <br /> Received By: Date: <br /> MU n�nn <br /> Riad i�n4� <br />