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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.orq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address:I / fJ A- C T_ To 1 6 n A C f , PeW 010-1 <br /> 0-1 /� I1 21 on ate: <br /> (v, Parameter/Standard tK M/eets SJC Standards? Comments/Measurements/ <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 Yes kZ No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes 2 No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes Q No ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes GX No ❑ NA❑ <br /> Seal between all pipe columns and casing Yes 5' No ❑ NA❑ <br /> Sounding tube/air vents sealed properly - Yes SCI No ❑ NA❑ <br /> Chlorination port available and sealed properly YesUlNoDINAD <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 M No ❑ NA❑ <br /> Adequately installed check valve or BFP device Yes Uf No ❑ NA ❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No ❑ INA Ig <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ I No ❑ INA[4 <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes [,� No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes a No ❑ NA ❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes KI 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: "d S Title: <br /> Received By: Date: <br /> A/AA InAA G <br />