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v 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.sicloy.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Addre : Ll <br /> L Q � _ , PtermitpLAU <br /> � Inspectio ate: <br /> V u 1�G IT7�.`- 9 V�1 � 24 1 <br /> r rj <br /> Parameter/Standard Meets SJC Standards? CommentslMeas cements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes Q No ❑ NA❑ <br /> Casing extends at least 12" above grade IYes ® 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❑ <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) l Yes ❑ No ❑ NA <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No❑ NA <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes [✓( No ❑ 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: C Title:GUI /Uvi �� A}Sj <br /> Received By: Date: <br /> C:u A W)n <br /> an�i�n�c <br />