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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.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Addr(p7S�s: . Q / / /(y//�Q�� Ple1r t#: Ins g/c7tio Date: <br /> ki, <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes [2 No ❑ NA ❑ <br /> Casing extends at least 12" above grade Yes [2 No ❑ NA ❑ <br /> Casing extends at least V above pedestal Yes 0 No ❑ NA ❑ <br /> Free of cracks/contiguous with annular seal Yes D No ❑ NA ❑ <br /> Graded to allow drainage away from casing Yes [0 No ❑ NA ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes [A No ❑ NA ❑ <br /> Seal between all pipe columns and casing Yes ® No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yes g No ❑ NA ❑ <br /> Chlorination port available and sealed properly Yes ❑ No ❑ NA �f <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 0 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 <br /> MAINTENANCE: <br /> Weil/Pump visible and protected from damage Yes © No ❑ NA El <br /> free from excessive vegetation Yes [7� 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 ❑ 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: aA^. Title: <br /> Received By: Date: <br /> C:u n0nn <br /> Qi� i�naG <br />