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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.si.gov.orn/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: 6' W s _ A 1 ,_ ` �� PO <br /> M33 2 Insp�ctyiorl Date: <br /> ff{(� I�� (—Q � of G'Ts �O <br /> Parameter/Standard Meets SJC Standards? <br /> Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes W No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes 0 No ❑ NA [I <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 W] No ❑ NA ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes U No ❑ NA ❑ <br /> Seal between all pipe columns and casing Yes VI 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 IL No ❑ NA ❑ <br /> Adequately installed check valve or BFP device Yes VI No ❑ NA ❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) I Yes ❑ No ❑ NA <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ 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 La 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 ❑ <br /> OTHER: <br /> Comments:11n 0 ���� � f <br /> P <br /> Inspected By: Ou, Title: <br /> Received By: Date: <br /> �u n)nn 0P4117n19 <br />