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SAN JOAQUIN COUNTY <br /> • ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> i e/ephone; (209)4.68-3420 Fax (209)468-3433 Web;www.siclov.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Perm <br /> S• ✓ ,t /Y � ' Inspecfion Dale: <br /> Parameter/Standard Meets SdC Standards? Comments/Measurements/ <br /> Recommenda�ians <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) IYes ❑ No NA❑ <br /> Casing extends at least 12" above grade Yes'K No ❑ NA❑ <br /> Casing extends at least V above pedestal Yes ❑ No NA❑ e�-}RI <br /> Free of cracks/contiguous with annular seal Yes No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes No ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and caAproperlyYes <br /> FNo <br /> NA❑ <br /> Seal between all pipe columns and cNA❑ <br /> Sounding tubelair vents sealed propNA <br /> Chlorination port available and sealeNA❑ <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❑ <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ <br /> MAINTENANCE: <br /> Well/Pump visible and protected from dama!�jYes,'Fl <br /> Yes noEj <br /> NA ❑ <br /> Well/Pump free from excessive vegetation 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: - <br /> inspected By: CAvt /4 n <br /> deceived By: Date: <br /> E34 n-inn <br />