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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTNI�NT <br /> 1868 East Hazelton Avenue, Stockton, CA 9%05-6232 <br /> i efephone:(209)468-3420 Fax: (209)468-34313 Web:\tWw.sigov.orglehd <br /> _ PUMP INSPECTION ChIECK LIST <br /> /�:ddress. Permit: Inspection Date: <br /> 2�0�'l r, ►�,� 'C'4--�cc� C,tb��r�,p_._. - p o�AN�t.;°� � � ��� <br /> ParameterlStandard Meets SJC standards? Comrnenis/Measurernentsl <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes d No ❑ INAD <br /> Casing extends at least 12" above grade Yes No ❑ NA❑ <br /> Casing extends at least 1" above pedestal Yes No ❑ NA❑ <br /> Free of cracks/contiguous with annular sealYes No ❑ NA El <br /> Graded to allow drainage away from casing Yes No ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes No ❑ INA ❑ <br /> Seal between all pipe columns and casing Yes No ❑ NA❑ <br /> Sounding tube/air vents sealed properly - Yes No [j 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 ki INo ❑ 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 1 ] NA❑ <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA 9 <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes E4 No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes No ❑ <br /> Permit drawing sufficient to locate well in future AeNo ❑ If'no'is selected,attach an accurate map to4rmit <br /> Photograph taken and attached to record No ❑ <br /> OTHER: <br /> Comments: <br /> n <br /> c <br /> Inspected By: Title: <br /> Received By: Date: <br /> r <br /> Y @ I a nrnd rnnee <br /> . ,_,.cif• '� 1�iY.►:=:' ..f ��, AY`.-.'�' •Aa'�,:�gyp :%• :p ty,�'�r- .. <br />