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.slgov.orq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Permit4: Inspection Date: <br /> '1 V G`� W 4 1,5� OZ lzS u� <br /> Parameter/Sfandard ft�feefs 5JC Standards? Comments/Measurements] <br /> Recommendations , <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes4, No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes No ❑ NA❑ <br /> Casing extends at least 1" above pedestal Yes No ❑ NA 0 <br /> Free of crackslcontiguous with annular seal Yes [A 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 d No ❑ NA❑ <br /> Seal between all pipe columns and casing Yes No ❑ NA ❑ _ <br /> Sounding tubelair vents sealed properly Yes [9J No ❑ NA❑ <br /> Chlorination port available and sealed properly Yes j 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 J No ❑ INA ❑ <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 ❑ No 4 NA❑ <br /> Air gap of at'least 6" (same as pipe diameter) Yes ❑ I No❑ NA <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes t No ❑ <br /> Permit drawing sufficient to locate well in future Yes q No ❑ if'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER: <br /> Comments: <br /> =Inspectedy _ Title: <br /> Received BY: Date: <br />