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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.orq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Perm ':: lnspe jplat-S• oS'T' 794 WooS-lo ioro <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) I Ye­sEk I No❑ INA❑ <br /> Casing extends at least 12" above grade IYesEjr INoEj INA❑ <br /> Casing extends at least 1" above pedestal IYes Q"INoE1 INA❑ <br /> Free of cracks/contiguous with annular seal Yes I No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes JNo ❑ INA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing YesWD <br /> Seal between all pipe columns and casing Yes <br /> Sounding tubelair vents sealed properly Yes Chlorination ort available and sealed properly Yes <br /> SAMPLE TAP AND BACKFLOW PREVENTION: <br /> Non-threaded sample tap between well head and arw� <br /> check valve or within 3' of well head lYesE] No NA❑ <br /> Adequately installed check valve or BFP device Yes U 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 IYes N=E]Permit drawing sufficient to locate well in future Yes Nh an accurate map to permit <br /> Photograph taken and attached to record Yes N <br /> OTHER: - - <br /> Comments: <br /> �1nspected By: Q.q�tsiu Title: QQ C 7� <br /> Received By: Date: <br /> cu ��nn <br />