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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.sinov.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: <br /> � Permit#: �- ., Inspe ion Date: <br /> o W • T e r �0d S 2 0 6 3 o 6 <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> GEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes 91 No ❑ INA❑ <br /> Casing extends at least 12" above grade Yes No ❑ INAD <br /> Casing extends at least 1" above pedestal Yes [A 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 IYes E& INo ❑ INA❑ <br /> Seal between all pipe columns and casing Yes 0 No ❑ NA❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑ NAM <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 <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 <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA Z <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes 4Z No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes 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 permit <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER• <br /> Com nts: <br /> n nv-.4 <br /> inspected By) Q-'t,, s\ Title:Ufa <br /> Received By: Date: <br /> cu AW)n <br />