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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazefton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 Web:www.si_gov.orq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Penn t#: Inspection Date: <br /> cW�M o � )ZZv `�� 6'�) X335 o\Il (0/7o�� <br /> Parameter/Standard Meets SJC Standards? Comments/Measurementsl <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes No El 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 El NA' F-1Graded to allow drainage.away from casing Yes No ❑ NA ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes No ❑ INA ❑ <br /> Seal between all pipe columns and casing TYesNo <br /> ❑ NA ❑ <br /> Sounding tube/air vents sealed properly ❑ NA ❑ <br /> Chlorination port available and sealed properly ❑ I 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 ❑ INA ElAdequately installed check valve or BFP device Yes j 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 <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No ❑ NA ❑ <br /> We11/Pump free from excessive vegetation Yes No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes A No ❑ <br /> Permit drawing sufficient to locate well in future MNoO <br /> No ElIf'no'is selected, attach an accurate map to permit <br /> Photograph taken and attached to record <br /> OTHER: <br /> Comments: <br /> Inspected By: Title: A T , <br /> Received By: Date: <br />