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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.slgov.orq/ehd <br /> PUMPIIN,S�PEC:TION CHECK LIST <br /> Ad ress; /� �`[ IJLI Pt,j P O O 3?6 3� /ZInsp7Ol ate; <br /> Parameter/Standard �J� Meets 5JC Standards? W Comments/Measuremenfsl <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4n minimum) IYes [Z No ❑ NA❑ &1-1 < �'X 3t <br /> Casing extends at least 12" above grade Yes © No ❑ NA❑ <br /> Casing extends at least 1" above pedestal Yes No ❑ NA❑ <br /> Free of crackslcontiguous with-annular seal Yes No ❑ NA❑ <br /> Graded to-allow drainage away from casing Yes Ej 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 tubelair vents sealed properly Yes ❑ No ❑ NA(� <br /> Chlorination port available and sealed properly Yes V 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 V NA E] rj <br /> s 1� <br /> Adequately instaIIed 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 JZ <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 V No ❑ NA❑ <br /> Well/Pump free from.excessive vegetation Yes © No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes N-60 <br /> Permit drjawing 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 /> - <br /> Inspected By: O � (y Title; '! <br /> Received By: Date: <br />