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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:wwvv.silaov.orq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address; <br /> Pe it#: Inspe'tion ate: <br /> Pi ST� a n( W R,PJ 1.6� 1 �m�ov��] PJ- 09 0 1 <br /> Parameter/Standard Meets SJC Standards? Comments/Measurementsl <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4u minimum) Yes Q No ❑ NA❑ <br /> Casing extends at least 12"above grade Yes t0 No❑ NA❑ <br /> Casing extends at least V above pedestal Yes 2 No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes 0 No❑ NA❑ <br /> Graded to allow drainage away from casing JYes V 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 [V No❑ NA F-1Sounding tubelair vents sealed properly Yes ❑ No F] NA[✓j <br /> Chlorination port available and sealed properly Yes [WNo ❑ NA❑ <br /> i <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❑ t <br /> No cross connectibns (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No❑ NA[V <br /> Air gap of at least 6" (same as pipe diameter) Yes❑ No❑ NA <br /> [MAINTENANGE:ell/Pump visible and protected from damage Yes No ❑ NA❑Vell/Pump free from excessive vegetation Yes No ❑ NA❑ISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes V 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 /> l <br /> Inspected By: Titleh ftt,,4v <br /> Received By: Date: <br /> cu A W)n <br />