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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.s►gov.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> FDn <br /> P it#: Inspe do Date: <br /> � ffrL1o ��i <br /> Parameter/Standard Meets SJC Standards? CommentslMeasuremf ntsf <br /> Recommendations <br /> EDESTAL: <br /> of surface seal (2'x2'x4" minimum Yeses No❑ NA❑ <br /> nds at least 12" above grade Yes No❑ NA❑ <br /> Casing extends at least V above pedestal Yes No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Y s No N. ❑ h r <br /> Graded to allow drainage away from casing Yes No❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing IYes No ❑ NA❑ <br /> Seal between all pipe columns and casing Yes � No❑ NA❑ <br /> Sounding tube/air vents sealed properly Yes No NAM <br /> Chlorination port available and sealed properly Yes V 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 I Yes No❑ NA ❑ <br /> Adequately installed check valve or 13FP device Yes No ❑ NA❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes❑ No D NA <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No❑ NA Q <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damageYes ;( No F1 NA ❑ <br /> Well/Pump free from excessive vegetation Yes No ❑ NA❑ T <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 /> Commenfis: <br /> • SSi` a.,. <br /> nspected By: SID Title: & V Ic1'D h a~'4A�' <br /> teceived By: ]Date: <br /> -u e-)nn <br />