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t <br /> 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.sigov.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Addres Permit#•9t Inspection Date: <br /> v� �3a�a6 <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes [Z] No ❑ NA ❑ <br /> Casing extends at least 12" above grade Yes 0 No ❑ INAD <br /> Casing extends at least 1" above pedestal Yes LZ 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 tube/air vents sealed properly Yes ❑ No ❑ NA EX r D s� <br /> Chlorination port available and sealed properly Yes a lNo ❑ 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 Z 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) jYesEj No ❑ INA <br /> Air gap of at least 6" (same as pipe diameter) jYesE1INoE] INAal <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes 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 EZ No ❑ if'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes W1 No ❑ <br /> OTHER: <br /> Comments: <br /> Inspected By' 1-,c l; Title: (�• !J Imo. <br /> Received By: Date: <br /> FH_a?nn_ 8/11112 015 <br />