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SAN JOAQUIN C OUN T Y <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:wwVv.sjgov.orq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: PermInspec'ion Date: , <br /> S7D -rb AJ 3 2 *_ -4 <br /> Parameter/Standard lhleets SJC Standards? onments/Measurements/ <br /> Recommendations <br /> EEE1`►l PEDESTAL: <br /> Gmensions of surface seal (2'x2'x4" minimum) Yes U' No ❑ INA ❑ <br /> Casing extends at least 12" above grade Yes [fie No ❑ INA ❑ <br /> Casing extends at least 1" above pedestal [Yes F.2 No ❑ INA❑ <br /> ,Free o ccracks/contiguous with annular seal IYes No I NA ❑ <br /> Graded to allow drainage away from casing IYes No ❑ NA ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes © I No ❑ NA ❑ <br /> Seal between all pipe columns and casing [Yes 0 No ❑ NA ❑ <br /> Sounding tubelair vents sealed properly IYes ❑ No ❑ NA 4 <br /> Chlorination port available and sealed properly I Yes [L] 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 1YesEv-1 No ❑ INA ❑ <br /> Adequately installed check valve or BFP device I Yes L2 No ❑ NA ❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from dornestic supply) Yes ❑ No ❑ NA ❑✓ I <br /> Air gap of at least 6'' (same as pipe diameter) Yes ❑ INoE1 NA [� <br /> ftflAINTENANCE: <br /> Well/Pump visible and protected from damage Yes WI No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes �z No ❑ INA ❑ <br /> MISCELLANEOUS,, <br /> Permit drawing represents actual location of well —Yes �1i No [:] I <br /> Permit drawing sufficient to locate well in future Yes F2 No ❑ It`no is selected, aftach an accurate map to permit <br /> [Photograph taken and attached to record Yes ( No ❑ <br /> 'OTHER: i <br /> Comments - I <br /> 1 \�C ►.S ()0(-4'I' �i}LJ CkT%,&r-,P— <br /> 4 l <br /> I iI <br /> Ij Ii <br /> I; <br /> I <br /> I <br /> i I <br /> Inspected By: SQ I Title: A <br /> Received By: I Date: <br /> cu nonn <br /> RI1d 71311a r <br />