Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> F ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.sicov.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Pmlt# I 1TC ©pec"jDate:6 <br /> ParameterlStandard Meets SJC Standards? Comments/Nieasurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4U minimum) IYes 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 YesEA <br /> 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 tubelair vents sealed properly Yes No ❑ NA❑ <br /> Chlorination port available and sealed properly Yes ❑ No ❑ NA 7Q <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 ❑ No❑ NA <br /> Adequately installed check valve or BFP device Yes ❑ No NA❑ N� <br /> No cross connections (ex. chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No❑ NA[Q� <br /> Air gap of at least Bu (same as pipe diameter) Yes ❑ No ❑ NA R <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: R nD, <br /> V 4 r/t <br /> nspected By: k Q <br /> Title: <br /> teceived By: Date: <br /> F:" n)nn <br />