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SAN.JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone; (209)468-3420 Fax: (209)468-3433 Web;www.sigov.orq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Perm 2 �8��on Date: <br /> �o G I D .S i Dc�1D t,,� &0 2,E J 2 �O <br /> ParameterlStandard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes 0 No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes ® No ❑ NA❑ <br /> Casing extends at least 1" above pedestal Yes V 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 [0 No ❑ NA❑ <br /> Seal between all pipe columns and casing Yes [2 No ❑ NA ❑ <br /> Sounding tubelair vents sealed properly Yes W 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 ❑ NAV <br /> Adequately installed check valve or BFP device Yes 4Z No ❑ NA❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No ❑ NA[P <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA <br /> MAINTENANCE: <br /> e1VPump visible and protected from damage Yes V No ❑ NA❑ <br /> WellfPump free from excessive vegetation Yes VF No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes S;� No ❑ <br /> Permit drawing sufficient to locate well in future Yes P 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 /> cl <br /> Inspected By: S Title: .1 R kS(s r <br /> Received By: Date: <br /> cu n�nn <br />