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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 CHET LIST _ <br /> Address: Permit#: fns ec'on Date: <br /> 16 L3 LAWp,�G C6- '►� Es iia �J Shoo �6 S�?I t� v1� <br /> Parameter/Standard 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 Ye No 2f NA ❑ Caste. 4D tom^ 1 z 4 �e <br /> Casing extends at least V above pedestal Ye No Q NA F-1Cash c .e/? i" <br /> Free of cracks/contiguous with annular seal Yes 0 No ❑ NA❑ I _ <br /> Graded to allow drainage away from casing Yes No ❑ NA ❑ <br /> SANITARY SEAL: -- --- <br /> Well is sealed between pump and casing Yes No ❑ INA❑ <br /> Seal between all pipe columns and casing Yes No ❑ INA ❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑ NA [•� <br /> Chlorination port available and sealed properly l Yes CZ No ❑ NAE] _ <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 0 No ❑ NA ❑ <br /> Adequately installed check valve or BFP device Yes 2 No ❑ NA ❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No ❑ NA[2 <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA Q <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes L2 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 Fj/j No ❑ lf'no'is selected, attach an accurate map to permit <br /> Photograph taken and attached to record Yes 0 No ❑ <br /> OTHER: <br /> Comments: n <br /> i� (iuJ PS cV / ��61�2 �C Fii 7 r� cj(' <br /> l� �' a� <br /> 1 Z a � - ,�- <br /> I /f <br /> Inspected By: Sn _ — _ Title: - /�}d,(IJ*�Q�1' <br /> Received By: Date: <br /> r7u nonn <br /> ❑na rOna F <br />