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' SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> 7e/ephone: (209)468-3420 Fax: (209)468-3433 Web:www.sigov.or4/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: S �r�.PJ N> V 1 L� -- - pSko 0-773 01 <br /> 9 � Inspection <br /> ? <br /> 2.-11) <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes Q No ❑ NA ❑ <br /> Casing extends at least 12" above grade Yes © No ❑ NA ❑ <br /> Casing extends at least V above pedestal Yes 0 No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes Z No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes [] No ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes 0 No ❑ NA ❑ <br /> Seal between all pipe columns and casing Yes g No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑ NA 0 <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 <br /> check valve or within 3' of well head Yes E ] No ❑ NA❑ <br /> Adequately installed check valve or BFP device Yes Z 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 No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes Fel 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 /> -1 <br /> Inspected By: Q.t� �� Title: E ' �' ASJ/S <br /> FQ- <br /> Received By: Date: <br /> CLJ AOM QIQ I tor)'G <br />