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r z 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;wvvw.sigov.org/ehd <br /> (� /^ PUMP INSPECTION CHECK /LIST 9 <br /> Address: 19 -70q <br /> �` I 1. ��U 0 L� S (� L 46A T uo 3 O a <br /> (J Permi ' �81Q94 <br /> nnSPP do bate: <br /> � <br /> Parameter/Standard Meets SJC Standards? ComrnentslMeasurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) IYesWoEDIN <br /> Casing extends at least 12" above grade Yes <br /> Casing extends at least 1" above pedestal Yes <br /> Free of cracks/contiguous with annular seal Yes <br /> Graded to allow drainage away from casing Yes No ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing YesE4 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 pork available and sealed properly Yes Ef 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; Q1 No ❑ NA❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes J No ❑ NA ❑ <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NAIYI <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of weII 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 UNo ❑ <br /> OTHER: <br /> Comments: <br /> Inspected BY: \ Title: <br /> Received By: Date: <br /> cu n�nn <br /> nr�a i�n�c <br />