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SAN JOAQUIN COUNTY <br /> ENVIRONIMEN T AL HEALTH DEPARTMEiN!T <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> 7efeplrone:(209)468-3420 Fax: (209)468-3433 ilJeh:v,rwvr.sigov.orq/ehd <br /> _PUMP INSPECTION C_f-_IECI( LIST <br /> Address:- Permit#: - Inspection Date: <br /> 0, Q C toSt. Z o %% a t'1 <br /> ParameterlSfandard hheets SJC Standards? connnlents/Nleasuremencs/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes No 6j 1 NA❑ <br /> Casing extends at least 12"above grade Yes j JNo ❑ NA❑ I <br /> Casing extends at least 1" above pedestal Yes A JNoEj NA❑ <br /> Free of cracks/contiguous with annular seal Yes NoFl, NA❑ <br /> Graded to allow drainage away from casing Yes j JNoEj NA❑ I <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes No ❑ INA❑ I <br /> Seal between all pipe columns and casing Yes JNoE1 NA❑ <br /> SoLIndin tube/air vents sealed properly - Yes No ❑ NA❑ <br /> Chlorination port available and sealed properly Yes INo ❑ NA❑ <br /> SAMPLE TAP A14D BACKFLOW PREVENTION: <br /> Non threaded sample tap between well head and <br /> check valve or within 3' of well head 4esNo❑ NAAdequately installed check valve or BFP device o ❑ 1\1A❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic Suppl Yes ❑ No NA <br /> Air cap of at lean 6" (same as pipe diameter) IYes ❑ INoD NA <br /> MAINTENANCE: <br /> 'Nell/Pump visible and protected from dais e Yes No ❑ NA. <br /> :Well/Pump free from excessive vegetation Yes I No ❑ I NA❑ <br /> ;[vII§CF.LLANEOL!S: <br /> Permit drawing represents actual location of Vvell Yes �No ❑ <br /> Penlllt drawing Sufficient to locate well in fU-ure IYes A No ❑ If'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes j INoE] <br /> OTHER: <br /> Comments: <br /> A <br /> �\\wA <br /> L <br /> ! <br /> Inspected By: Title: <br /> i <br /> Received 3y: Date: ____ <br />