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Y SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1 868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web;www.siciov.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: h ����� Co �f�V �� ��� i PU 0960 3 Intio Date: <br /> v .L. "WT loffit <br /> �( <br /> ParameterlStandard Meets SJC Standards? Comments/Measurementsl <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes G;� No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes Ra No ❑ NA❑ <br /> Casing extends at least 1" above pedestal Yes [-Lol 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 j [ 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 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 W <br /> MAINTENANCE: <br /> VVeIVPump visible and protected from damage Yes ® No ❑ NA❑ <br /> VVeII/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 /> c r <br /> Inspected 13y: CtM, c� � 'ntie: !J <br /> Received By: Date: <br /> cu A WM <br /> ni�ei�na� <br />