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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.siAov.oWehd <br /> PUMP INSPEC ION CHECK LIST <br /> Address:��� O � �I Y� � n ^ 1 (fin Pwho :uaz <br /> ��Inspe�io ate: <br /> ='�J 1�V <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/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 [4 No ❑ NA ❑ <br /> Casing extends at least 1" 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 S( No ❑ NA ❑ <br /> Seal between all pipe columns and casing Yes No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑ NA[� <br /> Chlorination port available and sealed properly Yes RT No ❑ NA❑ <br /> SAMPLE TAP AND BACKFLOW PREVENTION: <br /> Non-threaded sample tap between well head and Jap dh� <br /> check valve or within 3' of well head Yes ❑ No [Z NA ❑ <br /> Adequately installed check valve or BFP device Yes W No ❑ NA ❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No ❑ NA [0 <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 [./] No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes hZ 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 /> Comments: <br /> Inspected By: CU so Title: [4< SS(S <br /> Received By: Date: <br /> cu ��nn <br />