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Y SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> i etephone:(209) 468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address.- �� Perm t#: Inspe o Date: <br /> 7iL' I ESC'A WVC)--03S5?4,q llulgl/�? <br /> Parameter/Standard Meets SJC Standards? COmmentsWeasurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes 9 No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes V No ❑ NA❑ <br /> Casing extends at least 1" above pedestal Yes 2 No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes [0 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 ✓C7 <br /> Chlorination port available and sealed properly I Yes ( 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 a 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[r <br /> MAINTENANCE: <br /> WeWump 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 well Yes Ffzj 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: Title: f� a 1JP <br /> Received By: Date: <br /> Cu nonn <br /> arae rine G <br />