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r Y, 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.oiq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: "I�`� permi Measuremfnespnts/on <br /> ate: <br /> L ' ^ r �� ? w c)38 (+010-Nop'?Meets <br /> SJC StandardComments/Parameterl5tandard <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes ❑ No ❑ NA❑ D <br /> Casing extends at least 12" above grade Yes ❑ No ❑ NA❑ k LR <br /> Casing extends at least 1" above pedestal Yes ❑ No [I NA❑ <br /> Free of cracks/contiguous with annular seal Yes ❑ No E] NA E]Graded to allow drainage away from casing Yes ❑ No ❑ NA <br /> Di <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes V No ❑ NA❑ <br /> Seal between all pipe columns and casing Yes V1 No ❑ NA ❑ <br /> Sounding tubelair vents sealed properly Yes ❑ No ❑ NA[✓� <br /> Chlorination port available and sealed properly IYes F2 No ❑ NA ❑ <br /> SAMPLE TAP AND BACKFLOW PREVENTION: <br /> Non-threaded sample tap between well head and rf 0 <br /> check valve or within 3' of well head Yes ❑ No O7( NA❑ <br /> Adequately installed check valve or BFP device Yes 2 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 /> 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 /> C \ <br /> Inspected 13 Title: } -Ass�1 <br /> Received By: . Date: <br /> MU Amann <br />