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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.org/ehd <br /> PUMP INSPECTION <br /> J CHECK LIST `{ <br /> Address, I f t^ R ///1� R f,N Cj/ C���j) Sp b 66 () Ins ;tion.Date: <br /> Parameter/Standard 51 -' Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes d No ❑ NA ❑ <br /> Casing extends at least 12" above grade Yes V No ❑ NA ❑ <br /> Casing extends at least 1" above pedestal Yes [4 No ❑ NA ❑ <br /> Free of cracks/contiguous with annular seal Yes E6 No ❑ NA ❑ <br /> Graded to allow drainage away from casing Yes Pn No ❑ NA ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes 12f No ❑ NA ❑ <br /> Seal between all pipe columns and casing Yes © No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑ NA Z <br /> Chlorination port available and sealed properly I Yes © No ❑ NA ❑ <br /> SAMPLE TAP AND BACKFLOW PREVENTION: <br /> Non-threaded sample tap between well head and rro s w+> <br /> check valve or within 3' of well head Yes ❑ No fA 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 <br /> from domestic supply I Yes ❑ I No ❑ NA hZ <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes D No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes 0 No ❑ NA ❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes [A 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 [t No ❑ <br /> OTHER: <br /> Comments: <br /> No <br /> I <br /> MA AA24-, <br /> Inspected By: ss� Title: s i j <br /> Received By: Date: <br /> EH-4200- 8/31/2015 <br />