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f , <br /> .-'. 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 /> Address: � C� „ I � n Perm�® � ,e � � In�e tto'on Date: <br /> 6 <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) IYes V No ❑ NA❑ <br /> Casing extends 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 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 ❑ INA❑ <br /> Seal between all pipe columns and casing Yes No ❑ NA❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑ NA Ed <br /> Chlorination port available and sealed properly IYes No NZ NA❑ CL ` ah�, p6yt <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 [0 INA ❑ <br /> Adequately installed check valve or BFP device Yes W] No ❑ INA❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No ❑ NA 0 <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage YesNo E] NA ❑ <br /> Well/Pump free from excessive vegetation Yes No E] 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 51 No ❑ <br /> OTHER: <br /> Comments: <br /> Inspected By: Vctt, \ S Title: E F7�d[J f <br /> Received By: ]. Date: <br /> cu norm <br />