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r <br /> e r <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.slgov.orq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Permit#: Inspection Date: <br /> n 5 S E ALi bJ R -�sc�a�a /J � .SR oo-1-7837 <br /> Parameter/Standard Meets SJC Standards? Com ments/Measurem eats/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 1" 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 ❑ NA❑ <br /> Seal between all pipe columns and casing Yes No ❑ NA❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑ NA '�7( <br /> Chlorination port available and sealed properly IYes 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 ❑ NojZ NA 0 <br /> Adequately installed check valve or BFP device Yes kA No ❑ NA❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No INA <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ INA V <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes V No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes No ❑ NA ❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes [4 No ❑ <br /> Permit drawing sufficient to locate well in future Yes Q No ❑ If'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes [1j No ❑ <br /> OTHER: <br /> Comments: <br /> A0 sc.•,7,Ply �aP <br /> Inspected By: Title; ' 11q <br /> Received By: Date: <br />