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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95206-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:wwyd.sjgov.om&le <br /> PUMP R I°SPI...0 T ION CHECK LIST <br /> Address:�^ �._._ Permit:•� Inspec on Dte^3 A-�s� . � � 2o <br /> ParamceterlStandard Meets SJC Standards? ornmentslMeasurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> i <br /> Dimensions Of surface seal (2'x2'x4" minimum) Yes NA❑ <br /> Casing extends at least 12" above grade Yes No ❑ NA ❑ <br /> Casing extends at least T' above pedestal Yes [t I No ❑ NP,❑ <br /> Free of cracks/contiguous with annular seal Yes No ❑ NA❑ <br /> Graced 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 W <br /> Chlorination port available and sealed properly I Yes I 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 No ❑ NA ❑ <br /> Adequately installed check valve or BFP device Yes No ❑ NA ❑ <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 6" (same as pipe diameter) Yes ❑ INo ❑ NA 1` r <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes �' No ❑ NA El <br /> Well/Pump free from excessive vegetation Yes No ❑ NA ❑ <br /> MISCELLANEOUS: � <br /> Permit drawing represents actual location of well Yes r�j No ❑ <br /> Permit drawing sufficient to locate well in future Yes17? No ❑ I 'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes MINo ❑ <br /> I©THER: _ <br /> Carrirnenfs: <br /> Qn , <br /> < ���,, Cel �: Y- S �,�..n-���,� <br /> i <br /> n ; <br /> Inspected By: QA-' — S d - — --- ------- 'title: C—' �},JS!S <br /> —--- -- <br /> ��Received By: Date: <br /> — I. <br /> R�dinar, <br />