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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.siAov.orca/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: <br /> t Pe 't# Inspection Date: <br /> E --- 'K o �8�5 /0rtz/14- <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes [a No ❑ NA❑ <br /> Casing extends at least 12".above grade Yes [71 No ❑ NA❑ <br /> Casing extends at least 1" above pedestal Yes No ❑ NA❑ <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 casing Yes 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 Jj <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 fNo ❑ NA [J( <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 [Vj <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA Q� <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes g No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes No ❑ INA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes L6 INo ❑ <br /> Permit drawing sufficient to locate well in future Yes [0 No ❑ If'no'is selected, attach an accurate map to permit <br /> Photograph taken and attached to record Yes [0 No ❑ <br /> OTHER: <br /> Comments:: <br /> Inspected By: Q,jn -sI Title: +Vl Yp�ry�,Q al R� A9 f. <br /> Received By: Date: <br />