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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.sigov.orq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address.- <br /> 7-- �J _ : �� InQW?- <br /> Parameter/Standard <br /> Date: <br /> o E • �1 �►� 2 ` (.x,t'�1 FL 0 Meets SJC Standards? Comments/IV[e surements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) 1Yes Ej I No ❑ INA❑ <br /> Casing extends at least 12" above grade IYes a I No ❑ INA❑ <br /> Casing extends at least 1" above pedestal IYes SZ I No ❑ INA ❑ <br /> Free of cracks/contiguous with annular seal IYes No ❑ NA❑ <br /> Graded to allow drainage away from casing IYes No ❑ INA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing IYes 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 tap between well head and <br /> check valve or within 3' of well head I Yes ❑ INo❑_ NA <br /> Adequately installed check valve or BFP device YesNo El NA E"]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 ❑ No ❑ I N <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No ❑ INA ❑ <br /> Well/Pump free from excessive vegetation Yes No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes 9 No ❑ <br /> Permit drawing sufficient to locate well in future Yes W No ❑ If'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER: <br /> Commetatts: <br /> Inspected By: n INJ S 0 Title: nih -Ct" <br /> I <br /> Received By: Date: <br /> cu A,'�nn <br />