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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.siciov.orq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: _ <br /> U, J F �b G� , P� OO O �spe tion Date: <br /> N <br /> 107//6 <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) I Yes No❑ NA❑ <br /> Casing extends at least 12" above grade Yes No❑ONAE1Casing extends at least V above pedestal Yes [ No❑Free of cracks/contiguous with annular seal Yes j� No❑Graded to allow drainage away from casing Yes FV No ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes m No ❑ NA❑ <br /> Seal between all pipe columns and casing Yes � No❑ NA❑ <br /> Sounding tube/air vents sealed properly Yes No ❑ NA❑ <br /> Chlorination port available and sealed properly Yes No ❑ NA❑ <br /> SAMPLE TAP AND BACKFLOW PREVENTION: <br /> Non-threaded sample flap between well head and f <br /> check valve or within 3' of well head Yes No J2' NA❑ <br /> Adequately installed check valve or BFP device Yes ❑ No 2 NA❑ ✓i Ii 4,14 <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No[] NA[0 <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA[A-J' <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes 9jr No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes [ No E] NA F1 <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: - <br /> N0 S -�-�z a,�. oF` vi J��L� cC..� vqtvt- &V <br /> dj"1V(1 <br /> Inspected By: �� <br /> It <br /> Sfl,j „ <br /> Received By: Date: <br /> E=u t inn <br />