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SAN JOAQUII-\J. COUNTY <br /> Y <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 l=ax: (209)468-3433 Web;vV1A1Vd.sigov.orq/ehd <br /> PUMP ib° SPECT ION CHECK LIST <br /> Addr�^ t v .Sly'/ SlbTv�J <br /> per)P: Inspe tion ate. <br /> IA1,1, AAF � LA 00383d- 1 11 C ~I <br /> Pararneter/Standard Meets SJC Standards? CommentslAfeasurements/ <br /> Recommendations i <br /> CECVIENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes © No ❑ NA ❑ <br /> Casing extends at least 12" above grade Yes E�f No ❑ INA ❑ I �I <br /> Casing extends at least 1" above pedestal Yes [2 No ❑ I NA❑ <br /> ;Free of cracks/contiguous with annular seal Yes No ❑ INAD I <br /> Graded to allow drainage away from casing Yes [ I No ❑ NA ❑ <br /> SANITARY SELL: � <br /> Well is sealed between pump and casing Yes Q No ❑ NA ❑ <br /> Seal between all pipe columns and casing (Yes [i;� No ❑ NA ❑ I <br /> ?Sounding tube/air vents sealed properly Yes ❑ No ❑ NA E4 <br /> Chlorination port available and sealed properly Yes NA ❑ r <br /> SAMPLE TAP AND BACKFLOW PREVENTION: <br /> Non-threaded sample tap between well head and �v f-a-nlp�/A <br /> check valve or within 3' of wellhead Yes ❑ No [VNA ❑ <br /> Adequately installed check valve or BFP device Yes Q 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 /> jAir gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA 2 <br /> [MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes No ❑ INA ❑ <br /> MISCELLANEOUS. <br /> Permit drawing represents actual location of well Yes No ❑ I! <br /> Permit drawing sufficient to locate well In future Yes [2 No ❑ I 'no'is selected, atitech an accurate map to permit <br /> Photograph taken and attached to record Yes [V No ❑ <br /> (OTHER: <br /> !colni-flents; j <br /> I <br /> I! <br /> i y <br /> InspectedBy�0LL4't -- so (Title: �. �.}• A.s�4TG.i."1 <br /> V Received By: _ — — I Date:— — <br /> r_u norm RM1/o 1111.' <br />