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1 <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.om/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Permit Inspe ion�te: <br /> 3 0 0 8 5 K' K D 5 TF=2 9--b1�r� w pD o 3 7 d� / 111 2 u <br /> Parameter/Standard Meets SJC 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 1" above pedestal Yes D 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 No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑ <br /> Chlorination port available and sealed properly Yes No ❑ 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 ❑ NA ❑ <br /> Adequately installed check valve or BFP device Yes [Z No ❑ NA ❑ _ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation Q►J <br /> from domestic supply) Yes No ❑ I NA <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ I NA.7 <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes 2r No ❑ INA❑ _ <br /> Well/Pump free from excessive vegetation Yes �' No ❑ INA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes-0 No ❑ <br /> Permit drawing sufficient to locate well in future _ Yes Q 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 /> Inspected By: Ct.r Title: <br /> Received By: Date: <br /> C 4-I •0f)r) Q/'3 I/7neF <br />