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,v.ruv LVri�uty vvuivi t ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.slgov.org/ehd PUMP INSPECTION CHECK LIST Address: i O o f , L,� ,s� J / ��. PPr , �� n Iti'&I pion Date: l ('TN'h/ /�/ V Parameter/Standard Meets SJG Standards? Com meats/Measurements/Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes LZ No ❑ NA❑ Casing extends at least 12" above grade Yes 7 No ❑ NA❑ Casing extends at least 1" above pedestal Yes 0 No ❑ NA❑ Free of cracks/contiguous with annular seal Yes F✓ No ❑ NA❑ Graded to allow drainage away from casing Yes W No ❑ NA❑ SANITARY SEAL: Well is sealed between pump and casing Yes F�l No ❑ NA❑ Seal between all pipe columns and casing Yes ]1� No ❑ NA❑ Sounding tube/air vents sealed properly Yes d No ❑ NA ❑ Chlorination port available and sealed properly Yes ❑ No ❑ NA❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non-threaded sample tap between well head and check valve or within 3' of well head Yes M No ❑ NA❑ Adequately installed check valve or BFP device Yes V1 No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) 1YesE1 No ❑ NA 12 Air gap of at least 6" (same as pipe diameter) IYes ❑ No ❑ NA M MAINTENANCE: Well/Pump visible and protected from damage Yes ® No ❑ NA❑ Well/Pump free from excessive vegetation Yestf No ❑ NA❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes 0 No ❑ Permit drawing sufficient to locate well in future Yes F*,] No ❑ lf'no'is selected,attach an accurate map to permit Photograph taken and attached to record Yes 21 No ❑ OTHER: Comments: Inspected By: Title: Received By: Date: cu norm alae tone�