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x 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.org1ehd <br /> PUMP INSPECTION ;HECK LIST <br /> Address: I L, [�, �r 0 � / � Q <br /> l ✓ �' AIV I E \_> h!1 1 � PeW q 03IJ 5�d 0 Date: <br /> Parameter/Standard Meets SJC Standards? Commenfis/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) WoF-1 <br /> Casing extends at least 12" above grade <br /> Casing extends at least V above pedestal Free of cracks/contiguous with annular seal <br /> Graded to allow drainage away from casing Yes R� INo ❑ INA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes Qt No ❑ NA❑ <br /> Seal between all pipe columns and casing IYes Y No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑ NA W <br /> Chlorination port available and sealed roperly 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 Nod NA ❑ M f� w` 1 � v <br /> Adequately installed check valve or BFP device Yes No ❑ NA❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution systemfag flood irrigation <br /> from domestic supply) Yes ❑ No ❑ NA W <br /> Air gap of at least 6" (same as pipe diameter) 1 Yes ❑ No ❑ NA <br /> MAINTENANCE: <br /> VVe1VPump visible and protected from damage YeQZ1 No ❑ NA❑ <br /> WeIVPump free from excessive vegetation Yes No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes U INo ❑ <br /> Permit drawing sufficient to locate well in future Yes U No ❑ if`no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes 11 No ❑ <br /> OTHER: <br /> 31 <br /> Inspected BASS- <br /> Received By: ]. Date: <br /> =u n�nn <br />