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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 96205-6232 <br /> Telephone;(209)468-3420 Fax: (209)468-3433 Web;www.sigov.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: n n Tr / / / <br /> tJ 4 H K b f /G G Pe <br /> eJ K 0 b 6 C l7s�e n Date: <br /> Parameter/Standard Meets SJC Standards? Comments[Measuremenfisl <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 No❑ NA❑ <br /> Casing extends at least V above pedestal Yes 51 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 JNo ❑ NA❑ <br /> Seal between aI1 pipe columns and casing Yes [�' No❑ NA❑ <br /> Sounding tube/air vents sealed pro erly Yes No El NA❑ <br /> Chlorination port available and sealed properly Yes No❑ NA❑ <br /> SAMPLE TAP AND BACKFLOW PREVENTION: <br /> Non-threaded sample tap between well head and � Q,,�� <br /> check valve or within 3' of well head Yes ❑ No NA ❑ <br /> i <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 ❑ INo❑ NA 4 <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ jNo ❑ NA <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes JZ, No❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes 9 No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes No ❑ <br /> Permit drawing sufficient to locate well in future Yes Ejj No ❑ If-'no—ifs selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER; <br /> Comments: <br /> knspected By: Qw s U Title: A-5, is �' f- E <br /> Received By: Date: <br /> cu .-nn <br />