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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.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address' Permi Inspec ion D te• <br /> < Cutlr.e� �t- w ova 6` (p 1 30 , <br /> Parameter/Standard Meets 5JC standards? Comments/Measurementsl <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 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 F-1 - <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 �,�,> jA-1`'"1°/ <br /> check valve or within 3' of well head Yes ❑ No 2F NA ❑ <br /> Adequately instaIIed 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[0 <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No ❑ NA❑ <br /> Well/Pump free from.excessive vegetation Yes Z No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes © No'❑ <br /> Permit drawing sufficient to locate well in future Yes 9 No ❑ If°no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes 10 No ❑ <br /> OTHER: <br /> Comments: <br /> y4b S -jo� 4 <br /> Inspected 13y: Title; — <br /> , sSfs <br /> Received By: Date: <br />