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SAN JOAQUIN COUNT( <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Tefenhone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> P:ddress: l Permit#: 1;;�b <br /> on Date: <br /> �1 ,A 5�Z0� 1 l� 0. S 3`2A I 0 0 q 2.'t o Non <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes No ❑ NA❑ <br /> Casing extends at least 1" above pedestal Yes I No ❑ NA❑ <br /> Free of cracks/contiguous 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 ❑ NA❑ <br /> Chlorination port available and sealed properly Yes No ❑ NA❑ <br /> SAMPLE TAP AND BACKI=LOW PREVENTION: <br /> Non-threaded sample tap between well head and <br /> check valve or within 3' of well head Yes No ❑ NA❑ i <br /> Adequately installed check valve or l3FP device Yes Ij No ❑ NA❑ <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) I 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 A 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 /> —AWiVInspected By: --- — ---. -- Title: <br /> Received By: Date: <br /> .. h In A flla C <br />