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• SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> elephone: (209) 468-3420 l=ax: (209)468-3433 Web;wwyd.sjgov.orq/ehd <br /> PUMP INSPECTIOP41 CFIECK LIST <br /> Addre s: ---- Pere� _ Inspe ion D to <br /> PararneterlStandard I Meets SJC Standards? � Comments/Measurements/ <br /> p Recommendations <br /> IC1r "EENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) IYes [ No ❑ INADn ec, <br /> Casing extends at least 12" above grade Yes ❑ No ❑ NA ❑ <br /> Casing extends at least V above pedestal Yes ❑ No ❑ NA ❑ <br /> Free of cracks/contiguous with annular seal Yes ❑ No ® 1 NA ❑ <br /> Graded to allow drainage away from casing Yes No ❑ INA❑ <br /> SANITARY SEAL: I <br /> Well is sealed between pump and casing Yes © No ❑ NA❑ <br /> Seal between all pipe columns and casing Yes [V No ❑ INA ❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No 9 NA ❑ <br /> Chlorination port available and sealed properly Yes I No ❑ INA ❑ <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 ❑ �NAEI <br /> Adequately installed check valve or BFP device Yes No ❑ INA ❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> fi-om domestic supply) Yes ❑ No ❑ NA [0 <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA Q► <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes ® No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes V No ❑ INA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes No ❑ <br /> Permit drawing sufficient to locate well in future Yes No ❑ lf'no'is selected,aiiach an accurate map to permit <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER: <br /> Cornments: <br /> v <br /> f <br /> I <br /> --- — --- Lam, � <br /> Inspected icy: I S ' -- — -- Title: 6- 14- av/'j4zu <br /> Received By: Date: <br /> Cu n,)nn <br />