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8 <br /> Y SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 96205-6232 <br /> Telephone: (209)468-3420 Fax;(209)468-3433 Web;www.sigov.orq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: <br /> Per t#: Insp do qa` <br /> �� S mak- 'JL) Sly � bti% to o v38 6 S 0��2 <br /> Parameter/Standard Meets SJC Standards? Comments/Measuremenfis/ <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 1" above pedestal Yes-V No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes ❑ No [V NA r- <br /> Graded to allow drainage away from casing Yes V No ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes Z gEj <br /> ❑ <br /> Seal between all pipe columns and casing Yes V ❑ <br /> Sounding tube/air vents sealed properly Yes V NAE] <br /> Chlorination port available and sealed properly Yes ❑ <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 [Z <br /> Adequately installed check valve or BFP device Yes JZ No ❑ NA❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No ❑ NA E' <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA <br /> MAINTENANCE: <br /> Well/Purnp visible and protected from damage Yes g No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes 2 No ❑ <br /> Permit drawing sufficient to locate well in future Yes No F] 1f`no'is selected, attach an accurate map to permit <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER: <br /> Comments: <br /> rr <br /> Tr <br /> Inspected By: Title; <br /> Received By: Date: <br /> Cu norm <br />