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J/-11Y V VriW,VI1Y V'vU1V 1 I <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95206-6232 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:vwvw.sjgov.om/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: ✓✓� I Perm' ; `�Q <br /> GroVt � fe- L,J, , ryz�,t � -LZlit o-03 22 ,Up /tion p -, <br /> Parameter/Standard Meets SJG Standards? Com m e nts/M eas u rem entslRecommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes V No ❑ NA❑ <br /> Casing extends at Ieast 1" above pedestal Yes No ❑ NA ❑ <br /> Free of cracks/contiguous with annular seal Yes No ❑ N.A.❑ <br /> Graded to allow drainage away from casing Yes [2 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 9 <br /> Chlorination port available and sealed properly Yes L6 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 <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 /> V1/ell/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: <br /> Received By: Date: <br /> cu n)nn /one r- <br />