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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> • 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> iefephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.orq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Perm!4: Inspection Date: <br /> 1 S� u,51k 5bCk 0S 10 <br /> Parameter/standard [Meets SJC Standards? Coin mergfs/MeasuremerifsJ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes I No ❑ INA❑ <br /> Casing extends at least 12" above grade Yes d No ❑ NA❑ <br /> Casing extends at least T' above pedestal Yes [A No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes [a No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes [U No ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes INo INA ❑ <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 BACKFLOW PREVENTION: <br /> Non-threaded sample tap between well head and <br /> check valve or within 3' of well head Yes No ❑ NA❑ <br /> Adequately installed check valve or 13FP device Yes No ❑ NA ❑ <br /> No cross connections (ex: chernical feeders <br /> hooked to distribution system/ag flood irrigation <br /> frorn dornestic supply) Yes ❑ No 4 NA❑ <br /> Air gap of at least 6" (same as pipe diameter) IYes ❑ lNo ❑ INA Q <br /> MAINTENANCE: <br /> Well/Purnp visible and protected from damage Yes t I-No ❑ I NA❑ <br /> Well. ump free from excessive vegetation Yes [I] No ❑ NA❑ <br /> MISCELLANEOUS: <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 /> Inspected By: Title: I <br /> Received By: Date: <br /> fl fel.1 in/,A C <br />