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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95206-6232 <br /> Telephone: (209)468-3420 Fax. (209)468-3433 Web:www.sigoy.org/ehd <br /> ``((,, A + '' !! <br /> PUMP INSPECTION CHECK LIST <br /> Address: V � PC/v Wo ob L �l I vCk 7O Pwermip, 1 S e i7 ate: <br /> C <br /> Parameter/Standard Meets 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 ❑ No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes ❑ 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 Ye © No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly es W 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 and <br /> check valve or within 3' of well head Yes =o �D�NA ❑ <br /> Adequately installed check valve or BFP device Yes ® No ❑ INA ❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No ❑ INA[� <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No E] INA[j�' <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes W No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes 101 No ❑ NA❑ <br /> MISCELLANEOUS.• <br /> Permit drawing represents actual location of well Yes 2No ❑ <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: n <br /> Inspected I S® Title: f { ASS& <br /> Received By: Date: <br /> =u n�nn <br /> ava i�na� <br />