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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.sjclov.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Addres Pe t#: Inspect"on ate: <br /> 6 8 _75 - FT_ �'J'� S50 0 75333 a 9 <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes [Z No ❑ NA ❑ <br /> Casing extends at least 12" above grade Yes 2 No ❑ INA ❑ <br /> Casing extends at least 1" above pedestal Yes La No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes ® No ❑ NA ❑ <br /> Graded to allow drainage away from casing Yes No ❑ NA ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing — YesO No ❑ NA ❑ <br /> Seal between all pipe columns and casing Yes No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑ NA[V <br /> Chlorination port available and sealed properly Yes No ❑ NA❑ <br /> SAMPLE TAP AND BACKFLOW PREVENTION: <br /> Non-threaded sample tap between well head and a0 ,ra►�-p�:,s <br /> check valve or within 3' of well head Yes ❑ No NA ❑ <br /> Adequately installed 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 21 <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA[fl <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes ® No ❑ NA❑ _ <br /> Well/Pump free from excessive vegetation Yes 5Z No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes U 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: JQ Title: S�$ <br /> Received By: Date: <br /> =u e- <br /> ..u.w....wr <br />