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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)468-34•33 Web:wwvd.sigov.orq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address -1 <br /> "1'bsJ Perm' TI--spcfion Date: <br /> 4'�o -'�T IL98 s"-1bck — WT" <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: ~-- <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes 5Z No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes [2 No ❑ NA ❑ <br /> Casing extends at least 1" above pedestal Yes ® No ❑ NA ❑ <br /> Free of cracks/contiguous with annular seal Yes 0 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 [2 No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑ NA[� <br /> Chlorination port available and sealed properly Yes U 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 Q No ❑ NA ❑ <br /> Adequately installed check valve or BFP device Yes j2 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 ❑ 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 Fzj No ❑ <br /> Permit drawing sufficient to locate well in future Yes No ❑ I 'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER: - <br /> Comments: --- ---------- - _-- <br /> Qat <br /> i <br /> i <br /> Inspected By: �Lc. SO Title: • Asa,. <br /> Received By: Date: <br /> C:u A,)nn <br />