Laserfiche WebLink
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.sjgov.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Permit#: b a� Inspection Date: <br /> °� "�\�►Qch Q, N\� � v 3 � 3 Ob <br /> Parameter/Standard Meets SJC Standards? CommentslMeasurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal 2'x2'x4" minimum) Yes C No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes F,1 No ❑ NA❑ <br /> Casing extends at least V above pedestal Yes 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 ❑ NA ❑ <br /> Chlorination port available and sealed properly Yes [I 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 14 No ❑ NA ❑ <br /> Adequately installed check valve or BFP device Yes 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[e) <br /> MAINTENANCE: <br /> Well visible and protected from damage Yes No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes [;A 1NoE1 NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes No ❑ <br /> Permit drawing sufficient to locate well in future Yes No ❑ if'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes M No ❑ <br /> OTHER: <br /> Gornments: — - - <br /> Inspected By: Title: <br /> Received By: Date: <br /> n lnA lnnA[_ <br />