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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.om1ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Permit#• Inspe tion Date: <br /> E , JTo ck , L I n/o� J �� o �a6/s <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes [a No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes No ❑ NA❑ <br /> Casing extends at least 1" above pedestal Yes No NA ❑ ca n F�,., In 'r, cUk <br /> Free of cracks/contiguous with annular seal Yes [r] 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 ❑✓ No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑ NA ❑ <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 c S"7 it <br /> check valve or within 3' of well head Yes ❑ No,❑ NA ❑ <br /> Adequately installed check valve or BFP device Yeses 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[v( <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes Z 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 /> 1'j0 S � / <br /> cc's L ��n ►W 1 Il-' 'l t-�.c I 111,du �.��, 1-� <br /> Inspected By: Title: prSj1'j <br /> Received By: Date. <br /> �u Amann <br /> A/��/7111 F <br />