Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Tefe-phone:(209)468-3420 Fax:(209)468-3433 Web. www.sjgov.oM/ehd <br /> PUMP INSPECTION CHECK LIST <br /> l:ddress: Permif : Inspection Date: <br /> k)U, Il 20l <br /> ParameterlSfandard Meets SJG Standards? CommentslMeasurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes INo ❑ NA❑ <br /> Casing extends at least 12" above grade Yes E4 I No ❑ NA❑ <br /> Casing extends at least T' above pedestal Yes No ❑ NA❑ <br /> Free of cracksJcontiguous 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❑ <br /> Seal between all pipe columns and casing Yes No ❑ NA❑ <br /> Sounding tube/air vents sealed properly - Yes No [jNA L]Chlorination port available and sealed properly Yes No ❑ NA❑ <br /> SAMPLE TAIL AND BACKFLOW PREVENTION: <br /> Non-threaded sample flap between well head and <br /> check valve or within 3' of well head Yes j No ❑ NA❑ <br /> Adequately installed check valve or BFP device Yes No ❑ NA ❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> frorn domestic supply) Yes ❑ No 4 NA ❑ <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA <br /> MAINTENANCE: <br /> Well visible and protected from damage Yes .No ❑ NA ❑ <br /> WelllPump free from excessive vegetation Yes No ❑ NA ❑ <br /> MISCELLANE0US. <br /> Permit drawing represents actual location of well Yes 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: <br /> L ���` <br /> Inspected Cay: -- — -- - - -- I Title: <br /> Received By: Date: <br /> .. nfn.11.111A G <br />