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u0j-"V Vvrifa(V11V v'lJuiYI I <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.oM/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: r Permit#: Ins ctio Date: <br /> t4 h7 k Ll- 5r P.D c-fCA Lo"1 �vo� �� 1 � to(o3�1� <br /> Parameterl5tandard Meets SJG Standards? Com m ents/M eas u rem entslRecommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes D No ❑ INA❑ <br /> Casing extends at least I" above pedestal Yes © No ❑ NA❑ <br /> Free of crackslcontiguous with annular seal Yes [�j 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 ❑ NA❑ <br /> Seal between all pipe columns and casing Yes Q No ❑ NA❑ <br /> Sounding tube/air vents sealed properly Yes [0 No ❑ NA❑ <br /> Chlorination port available and sealed properly Yes &If 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 I lNo ❑ �NA❑ <br /> Adequately installed check valve or BFP device Yes U No ❑ I NA❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) IYesF No ❑ NA[' <br /> Air gap of at least 6" (same as pipe diameter) IYes ❑ No ❑ NA[V <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes 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, attach an accurate map to permit <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER: <br /> Comments: <br /> lj,, ,IleC( <br /> Inspected By: Title: &P, JJiJ 4L44 <br /> Received By: Date: <br /> cu AOnn <br /> niaI�n � <br />