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SAN JOAQUIi! COUNTY <br /> ENVIRONMENTAL HEALTi- DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fex: (209)468-3433 Web:wA/yd.sjgov.orq/ehd <br /> PUMP [INSPECTION CHECK LIST <br /> Address: � --M� �J-.1 � --9-wCt C�^Per'mi�y;o Inspection Da e: <br /> f W��// 31� 7� 01 <br /> Y Parameter/Standard Meets SJC Standards? Cornmenfs/illeasurements/ <br /> - -- -�.— ----- — v_ _� --- Recommendations --CEMENTPEDESTAL.' <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes & No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes No ❑ NA❑ <br /> Casing extends at least V above pedestal Yes ® No ❑ NA ❑ <br /> Free of crackslcontiguous with annular seal Yes 2 No ❑ INA❑ <br /> Graced to allow drainage away from casing Yes FV1 I No ❑ INA❑ <br /> SANITARY SEAQ.: <br /> Well is sealed between pump and casing Yes [�A No ❑ NA ❑ <br /> Seal between all pipe columns and casing Yes No ❑ NA ❑ <br /> Sounding tubefair vents sealed properly Yes No ❑ NA ❑ <br /> Chlorination port available and sealed properly Yes No ❑ I 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 EL2, 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 W <br /> MA1NTENANGE: <br /> Well/Pump visible and protected from damage Yes 0 No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes 2 No ❑ NA ❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes Fv-j INo ❑ <br /> Permit drawing sufficient to locate well in future Yes Q No ❑ `no'is selected, attach an accurate map to permit <br /> Photograph taken and attached to record Yes [ No ❑ <br /> 10TH'I R: <br /> Comments: <br /> I <br /> Inspected Sy: a,, s� Title: <br /> Received By: Date: <br /> cu ionn <br /> n2ona <br />