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dt119 10 lilt vvUly I I <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 96206-6232 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:vwvw.sjgov.orq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Pe t#: Insp tion Date: <br /> r as <br /> ParameterlStandard Meets SJC Standards? Comments/Measurements!Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes W No ❑ INA❑ <br /> Casing extends at least 12» above grade Yes V No ❑ NA❑ <br /> Casing extends at least 1" above pedestal Yes ® lNo ❑ NA ❑ <br /> Free of crackslcontiguous with annular seal Yes Z No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes Q 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 9 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 [Z No ❑ NA❑ <br /> Adequately installed check valve or BFP device Yes V 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[l� <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes 2 No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes V 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: S Title: <br /> Received By: Date_ <br /> cu nonn <br /> nna lone� <br />