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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEAL:Ffi DEAR-I'MENT <br /> 1868 East I-lazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-34.20 Fax. (209)468-3433 Web:vAvw.sjqov.orq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Pennft#: <br /> TR A LI/ WP003'7M2- Inigp tiara <br /> Meets$JC Standards? Comments/Measurements/ <br /> Parameter/Statidard Recommendations <br /> CEMENT PEDESTAL: <br /> f ns ensi <br /> Dimoosurface seal (2W'x4� minimum) Yes No----—-----1-------- 0 NAEJ <br /> Casing extends at least 12" abovegrade__ Yes <br /> Casing exte_nds at.least 1' above edestal s �NoFj NAD <br /> Free of cracks/conticlUOUS with annular seal Yes � No El NA El <br /> Graded to allow draina e away from casco Yes NA <br /> SANITARY SEAL: <br /> Well is sealed betweetLp iDp and casing_ Yes M No Ej NA <br /> Seal between all_pipe columns and casing Yes [2 No NA <br /> No <br /> SounLing tube/airvents sea led to ly <br /> .... <br /> -........... ... <br /> Chlorination port available and sealed properlya Yes Na5kt1:::LNA <br /> _JaL_ <br /> SAMPLE TAP AND BACKFLOW PREVENTION: <br /> �o—n--th-re—ad--ed—sa`rn-p—le-—tap-,b-e-tw--e—en-`w—ell _WaJ—aTd <br /> check valve or within 3' of well head Yes j No NA <br /> _alled check valve or BFP device Yes No <br /> No cross connec�uor'is (ex: cl"i'em-i'caffeeders-, <br /> hooked to distribution system/ag flood irrigation <br /> from domestic su Yes El No Ej I NA[Z <br /> Airqpp�at Least L(same as�ipe diameter) s No [:].,INA[9 <br /> _�L_ ) __ <br /> MAINTENANCE:.---- <br /> Well/Purnp visible and protected from dame A <br /> Ne Ye�[�_1��[a A__n <br /> Well/Pump free from excessive veg tation A <br /> MISCELLANEOUS: <br /> Permit draw_ inq represents actual location of well No <br /> Permit drawin sufficient to locate well in future Yes No Ivnets selected,attach an SCCLIrate reap to permA <br /> Photo g[aft Laketj-@-nd attached to record Yes lio--Q- <br /> OTHER: <br /> Comments: <br /> Ins ectad B <br /> Received Date: <br />