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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: PerIns a tion ate: <br /> Parameter/StandardH16-0, WS19oli R-D Obd. P0: 03756 � _.j <br /> Comm a nts/Meas u rem encs/Meets SJC Standards? Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2 x4" minimum) Yes No ❑ NA El <br /> Casing extends at least 12" above grade Yes © No ❑ NA ❑ <br /> Casing extends at least 1" above pedestal Yes 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 No ❑ NA❑ <br /> Seal between all pipe columns and casing Yes 0 No ❑ NA❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑ NA[V <br /> Chlorination port available and sealed properly Yes 62 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 0 <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 <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes &Z No ❑ INA❑ <br /> Well/Pump free from excessive vegetation Yes No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes 2 No❑ <br /> Permit drawing sufficient to locate well in future Yes [2 No ❑ lf'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes Q No ❑ _ <br /> OTHER: <br /> Comments: <br /> 444 <br /> Inspected By: OtM Title: h S H. Ckl!I- <br /> Received By: Date: <br />