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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.org/ehd <br /> PUMP W SPECT(ON CHECK LIST <br /> Address: Perm : <br /> log loo RPrvC-.S �t� m T6�& WVal? 3� 4T"�rN <br /> Parameter/Standard Meets SJC Standards? CommentsllYleasurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes [V No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes [d No ❑ NA❑ <br /> Casing extends at least 1" above pedestal Yes W No ❑ NA ❑ <br /> Free of cracks/contiguous with annular seal Yes V No ❑ NA❑ <br /> Graded to allow drainage away from casing INo0 NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes [V No ❑ NA ❑ <br /> Seal between all pipe columns and casing Yes No ❑ NA ❑ <br /> Sounding tubelair vents sealed properly Yes ❑ No ❑ NA 2 <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 Q lNoE] 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 2 <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NAWI <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No ❑ INA❑ <br /> Well/Pump free from excessive vegetation Yes VF No ❑ INA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes No ❑ <br /> Permit drawing sufficient to locate well In future Yes No ❑ 11'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: SO — — -- — Title: H. ASSGf'.S <br /> Received By: - - _ Date: <br /> r_u Amann <br />