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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 /> Address, �Q �7/ Q <br /> C�U !'l t—T 40 `{ p� 'Q 0 /D ( in�ection Date: <br /> y a <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) IYes 12 No ❑ INA❑ <br /> Casing extends at least 12" above grade Yes No ❑ NA ❑ <br /> Casing extends at least 1" above pedestal Yes No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes [A No ❑ NA ❑ _ <br /> Graded to allow drainage away from casing Yes [0 No ❑ NA ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing YesM 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 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 EZ 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 J;Z No ❑ NA❑ <br /> Air gap of at least 6" same as pipe diameter) Yes C❑ No ❑ NAM, <br /> MAINTENANCE: <br /> WellIPump visible and protected from damage Yes V No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes V No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes 5Z 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 No E] <br /> OTHER: <br /> Com nts: <br /> r <br /> CIQ <br /> i s OL4,-{ <br /> Inspected By: IJSK2 Title: L/I ry <br /> Received By: Date: <br /> cu n)nn <br />