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Y SAN JOAQUIN COUNTY <br /> s <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address c Per w Inspe 'on Daae: <br /> P-Ir t 3 9 061'.n <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes ❑ No ❑ NA❑ /V0 <br /> Casing extends at least 12" above grade Yes ❑ 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 2 No ❑ NA ❑ <br /> Sounding tubelair vents sealed properly Yes ❑ No ❑ NA Q' <br /> Chlorination port available and sealed properly IYes 2 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 g No ❑ INA ❑ <br /> Adequately installed check valve or BFP device Yes 9 No ❑ NA ❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No ❑ NA[j <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA E�r <br /> MAINTENANCE: <br /> WeIVPump visible and protected from damage Yes ® No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes Vr 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 /> eacf <br /> Inspected By: k.tn S o Title: kJ <br /> Received By: Date: <br /> cu ��nn <br />