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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.org/ehd <br /> PUMP INSPECTION CHECK LIST _ <br /> j <br /> Address: Permita: Inspection Date: <br /> __L '� "�5 VSQ by 3 0 12 I l 0 l <br /> Parameter/Standard Meets SJC Standards? Comments[Measurements] <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes [j No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes No ❑ NA❑ <br /> Casing extends at least V above pedestal YesEd No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal YesNo J NA❑ b�S L <br /> Graded to allow drainage away from casing Yes No ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes N jNo ❑ NA ❑ <br /> Seal between all pipe columns and casing Yes No ❑ NA❑ <br /> Sounding tubelair vents sealed properly Yes Fj No ❑ NA ❑ <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 1� INAE] LN Lv_-T4,,x. 51V Q„c_ <br /> Adequately installed check valve or BFP device Yes [j No ❑ INA ❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes FJ 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 YesEj No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes Ej No ❑ <br /> Permit drawing sufficient to locate well in futureYes No [:1If'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: Title: f 7 <br /> Received By: Date: <br />