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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.sjgov.orq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: r � ( n�� Pw rvo 3 z� I11 e�2ction;ate: <br /> G U�O if/' �/ <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes ©' No ❑ NA ❑ <br /> Casing extends at least 12" above grade Yes © No ❑ NA ❑ <br /> Casing extends at least 1" above pedestal Yes [2 No ❑ NA ❑ <br /> Free of cracks/contiguous with annular seal Yes a No ❑ NA ❑ <br /> Graded to allow drainage away from casing Yes EA 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 F2 No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑ NA [� <br /> Chlorination port available and sealed properly Yes No ❑ NA ❑ <br /> SAMPLE TAP AND BACKFLOW PREVENTION: <br /> Non-threaded sample tap between well head andq� <br /> check valve or within 3' of well head Yes ❑ No F1 NA ❑ b wea a <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 FI' <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes a No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes 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 ❑ lf'no'is selected, attach an accurate map to permit <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER: <br /> Comments: ` <br /> ic C:e fteAJ Cc-C r S�vrrc i ��L� tj-u 1,P A c1 <br /> Inspected By: Sv Title: Asj IS Gjh <br /> Received By: Date: <br /> C-u n)nn <br /> ❑1o4i0n4 c <br />