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Y 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.sjgov.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: ] q / r /� -7 Inspe on�aatte: <br /> ` l co 1 C G C.IJ CIeIkLt Permif#P M� /�9 J Z, z�]1(O <br /> Parameter/standard Meets SJC Standards? •lNp Comments/`Mreasurementsl <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes © No ❑ NA❑ <br /> Casing extends at least 12" above grade JYes DNo ❑ NA❑ <br /> Casing extends at least 1" above pedestal Yes [2 No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes 2 No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes No ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing IYesWNAI[o <br /> Seal between all pipe columns and casing Yes Sounding tube/air vents sealed properly YesChlorination port available and sealed properly Yes ❑ <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 Y1 <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA[V <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damageYes{�] No [INA ElWell/Pump free from excessive vegetation ]Yes [ No ❑ INA ❑ <br /> FEE <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes No ❑ <br /> Permit drawing sufficient to locate well in future Yes 0 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 /> I � <br /> Inspected By: �� Title: �3S1J <br /> Received By: Date: <br /> �-u AOnn <br />