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dril Y V vttta(V 1111 V V U l V 1 I <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone; (209)468-3420 Fax. (209)468-3433 Web;vwvw,sigov.orq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: peri _ <br /> S` 866 C c-�' �� LSCA Lo, ���� '1Dnsp7v'`3 <br /> ParameterlStandard Meets SJG Standards? Com ments/Meas u rem encs/Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) IYes 2 No ❑ NA❑ <br /> Casing extends at least 12" above grade I Yes 2 No ❑ NA❑ <br /> Casing extends at least I" above pedestal Yes [2 No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes 0 No F1NA❑ <br /> Graded to allow drainage away from casing Yes No ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes M No ❑ NA❑ <br /> Seal between all pipe columns and casing Yes © No ❑ NA❑ <br /> Sounding tube/air vents sealed properly Yes W No ❑ NA❑ <br /> Chlorination port available and sealed properly Yes W No ❑ NA❑ <br /> SAMPLE TAP AND BACKFLOW PREVENTION: _ <br /> Non-threaded sample tap between well head and tj <br /> check valve or within 3' of well head Yes ❑ No [dFNAF 0 <br /> Adequately installed check valve or BFP device Yes [2 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[' <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes [2 No ❑ NA❑ <br /> VVell/Pump free from excessive vegetation Yes Z No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes No ❑ <br /> Permit drawing sufficient to locate well in future Yes No ❑ If`no'is selected,attach an accurate map to pemZit <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER: <br /> Comments: <br /> Inspected By: r4so Title: ffk4l-f <br /> Received By: Date: <br /> cu AOnn <br />