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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.slgov.orq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Perm[ Inspe tion ate: <br /> C A-19P LCI �COP� POO 3 6�s i� 3 <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes 9 No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes © No ❑ NA❑ <br /> Casing extends at least T' 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 9 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 [:1 No ❑ NA V] <br /> Chlorination port available and sealed properly Yes�A 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 [0 No ❑ NA❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No ❑ NA Q <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage iYes M I No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes{_/1 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 [17 No ❑ _ <br /> OTHER: <br /> Co ments: <br /> PP G � � reset( ��� ►h s•ttrl,:� <br /> Inspected By: <br /> Title <br /> Sn Title: <br /> Received By: Date: <br /> 1 A(nA In/1AC <br />