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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 l=ax. (209)468-3433 Web:wwvd.sjgov.orq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address:( tt p D Per if4:/� <br /> 1 l I J 1 1 Ef 9.:D k&jc/4 C fry'►to �O V t Sp ciion,D'ate: <br /> ParameterlStandard 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 M No ❑ NA ❑ <br /> Casing extends at least V above pedestal Yes 2 No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes No ❑ NA❑ <br /> Graded to allow drainage away from casing I Yes No ❑ NA ❑ <br /> SANITARY SEAL: I <br /> i <br /> Well is sealed between pump and casing Yes No ❑ NA ❑ <br /> Seal between all pipe columns and casing Yes lNo ❑ NA ❑ <br /> Sounding tubelair vents sealed properly Yes ❑ No ❑ NA 0 <br /> Chlorination port available and sealed properly Yes [2 No ❑ NA ❑ <br /> SAMPLE TAP .AND DAGKFLOW PREVENTION: <br /> Non-threaded sample tap between well head and <br /> check valve or within 3' of well head Yes f No ❑ NA ❑ <br /> Adequately installed check valve or BFP 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 ❑ NA Rv <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ INoD NA &v <br /> MAINTENANCE: <br /> Well/Purnp visible and protected from damage Yes LZ No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes 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,a«ach an accurate map to permit <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER: <br /> Comments: <br /> f Ilk <br /> �rr <br /> Inspected By: V — — ---- - Title: 4S <br /> 6 ---- <br /> Received By: Date: <br /> CW n)nn <br /> Qrz�ionar <br />