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T A <br /> SAN JOAQUIN COUNTY <br /> y ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209)468-3420 Fax; (209)468-3433 Web:www.sigov.orglehd <br /> PUMP INSPECTION CHECK LIST <br /> Address:13 <br /> � Perm Inspe 'on D te: <br /> JC 3 4 v C m'�"� Q 0�3 8 6 if o� 1 � <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements! <br /> Recommendations <br /> GEMENT PEDESTAL; <br /> Dimensions of surface seal (2'x2'x4" minimum) I Yes C1 No ❑ NA© <br /> Casing extends at least 12" above grade Yes © No ❑ NA❑ <br /> Casing extends at least V above pedestal Yes❑ No ❑ NAM <br /> Free of crackslcontiguous with annular seal Yes ❑ No ❑ NA 0 <br /> Graded to allow drainage away from casing Yes ❑ No ❑ NA j <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes © No ElNA❑ <br /> Seal between all pipe columns and casing Yes © No ElNA EJ <br /> Sounding tubefair vents sealed properly Yes F] No El NA[2 <br /> Chlorination port available and sealed properly Yes 17 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) Yes ❑ No ❑ NA Q <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ jNo ❑ INA Q <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes [�4 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 /> 0 l � <br /> Inspected By: Title: <br /> Received By: Date: <br /> E34 n inn � A <br />