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SAN JO1-QUIN COUNTY r`� <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.orq/ehd <br /> G� /� PUMPS INSPECTION CHECK LIST �o,,/� p <br /> Addres l 6 1. � �' V`/ ,Elf 0 /v Perm!(,� PVV 3O Inspe fion Date- <br /> 106, <br /> 3 3a /8 <br /> Parameterl5tandard Meets 5JC standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <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 I" above pedestal Yed © No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes W1 No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes J�] No ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes U No ❑ NA❑ <br /> Seal between all pipe columns and casing Yes V1 No ❑ NA ❑ <br /> Sounding tubefair vents sealed properly Yes W1 No ❑ NA❑ <br /> Chlorination port available and sealed properly Yes W No ❑ NA❑ <br /> SAMPLE TAP AND BACKFLOW PREVENTION: <br /> Non-threaded sample tap between well head and evo fci,, j j <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 M <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA EK <br /> MAINTENANCE: <br /> WelVPump visible and protected from damage Yes R No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes ]2 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 [0 No ❑ <br /> OTHER: <br /> Comments: <br /> NTJS � f '' <br /> Inspected By: CLI, Title: AlIvJ <br /> Received By: Date: <br /> �u AOnn <br /> nrarine� <br />