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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.sigov.orq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: c ' r —�f7 1_ � e /•� <br /> (? SJ N ilk p'�/ p 3 V 7 V , �nD p ctio Date: <br /> Parameter/Sfiandard Meets�SJGtandards? Comments[Measurelments/ <br /> Recommendations <br /> CEMENT PEDESTAL- <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes No❑ NA❑ <br /> Casing extends at least 12" above grade Yes No❑ NA❑ -- <br /> Casing extends at least V above pedestal Yes 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 Yes No❑ NA❑ <br /> Seal between all pipe columns and casing Yes M No❑ NA❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No❑ NA <br /> Chlorination port available and sealed properly Yes ❑ No ® NA❑ a} Aug <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 �j No ❑ NA❑ <br /> No cross connections (ex: chemical feeders - - -- <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No❑ NA j 5� <br /> Air gap of at least 6" same as pipe diameter) Yes ❑ No❑ NA <br /> MAINTENANCE: - <br /> WellfPump visible and protected from damage Yes 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 ❑ lf'no' sected,atachaaccurate map to permit <br /> Photograph taken and attached to record Yes [ No ❑ <br /> OTHER: <br /> Comments: ff — <br /> aspected By: aA. d Title: h4 KY' <br /> Zeceived By; Date: <br /> cu n-nn <br />