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SAN JO AQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> 7 efej)hone:(209)468-3420 f=ax: (209)468-3433 Web:www.sjgov.or /q ehd <br /> PUMP INSPECTION CHECK LIST _ <br /> p:ctdress: � y Permit#.: � Inspection Date: <br /> C.,�N�Qb o O 3d,S\\. Z ?-0 <br /> Parameter/Sfanctard - -- Meets SJC Standards? Comments/Measureme ts/ <br /> Recommendations <br /> E:,EMENT PEDESTAL <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes 01 No ❑ NA❑ <br /> Casing extends at least T' above pedestal Yes No ❑ NA❑ <br /> Free of crackskontiguous with annular seal Yes No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes IM No ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes Kh 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 /> SA PLE 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 BFP device Yes No ❑ NA❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No J NA❑ <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NAEd <br /> MAINTENANCE: ..Well <br /> /Pump visible and protected from damage Yes No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes No ❑ INA,D <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes Ej 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 /> IOTHER: <br /> C ommeii-ts: <br /> I <br /> i <br /> Inspected By: Title: <br /> Received By: Date: <br /> . nr�a innac <br />