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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.sjgov.orq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address- Permiit#: <br /> 71/ 6e: <br /> vV 'l CL ` (�V� JOunl1 VE k /OJ 59,00-1733'6 e <br /> Parameter/Standard I Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes W No ❑ NA ❑ _ <br /> Casing extends at least 12" above grade Yes © No ❑ NA ❑ <br /> Casing extends at least 1" above pedestal Yes ® No ❑ NA ❑ <br /> Free of cracks/contiguous with annular seal Yes 0 No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes I�K No ❑ NA ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes ® No ❑ NA ❑ <br /> Seal between all pipe columns and casing Yes V1 No ❑ NA ❑ <br /> Sounding tubelair vents sealed properly Yes ❑ No ❑ NA 2 _ <br /> Chlorination port available and sealed properly I Yes 21 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 Yes g No ❑ NA ❑ <br /> Adequately installed check valve or BFP device Yes V No ❑ NA ❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation Ll <br /> from domestic supply) Ye9TA No ❑ NA IV <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA JA <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes LA No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes [Z No ❑ INA❑ <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: Title: "E' 14. <br /> Received By: Date: <br /> cu nonn <br /> Rna �ne F <br />