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z SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1 868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax; (209)468-3433 Web:www.sigov.orglehd <br /> PUMP INSPECTION CHECK LIST <br /> Address Pw, ()3 (nsp ction ate: <br /> JS• cAsTL 6 D , �nwEc�- <br /> 0 <br /> Parameter/Standard Meets SJC Standards? CommentslMeasurementsl <br /> 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 :::dYes`j] No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes [✓f 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[4 <br /> Chlorination port available and sealed properly 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 No ❑ NA❑ <br /> Adequately installed check valve or BFP device Yes No ❑ NA F-1No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No F-1NA[V <br /> Air gap of at least 6" same as pipe diameter) Yes ElNo ❑ NA[v� <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes V No ❑ ONAOWell/Pump free from excessive vegetation Yes 0 No ❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes © No ❑ <br /> Permit drawing sufficient to locate well in future Yes 0 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: YCLIdJ Title: - !"� ► 7•fd(J �I <br /> Received By: Date: <br /> cu n�nn <br /> nrns...n..- <br />