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SAN JOAQUIN GOUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT' <br /> '1868 East Hazelton Avenue, Stockton , CA 95205-6232 <br /> Tetephone: (209) 468-3420 Fax: (209) 468-3433 Web : yvvvntv.sigov. orq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: ��,v� j / 'Q �^ ,� ( y `, r sp <br /> 5 '� ' �� �} W lQ /�1 �c� k � r J G�, (� Q U v 1 �` tionpate : <br /> ParameterlStandard Meets SJC Standards ? Comments/Measurements/ `/ <br /> Recommendations <br /> CEMENT PEDESTAL : <br /> Dimensions Of s >_Irface sea ( 2'x2 'x4" minimum )Aes <br /> No ❑ NA ❑ _ <br /> Casing extends at least 12 " above grade No ❑ NA ❑Casing extends at least 1 " above pedestal No ❑ NA ❑ <br /> Free of cracks/contiguous with annular seal No ❑ NA ❑ <br /> Graded to allow drainage away from casing No ❑ NA ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing _ Yes No ❑ NA ❑ _ <br /> Seal between all pipe columns and casing Yes EA. No ❑ NA ❑ <br /> Sounding tubelair vents sealed properly Yes ❑ No ❑ NAM <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 YesZL No ❑ NA ❑ <br /> Adequately installed check valve or BFP device Yes .► No LJ NA ❑ <br /> No cross connections (ex : chemical feeders <br /> kMAINTENANGE: 21 <br /> distribution system/ag flood irrigation <br /> stic supply) Yes ❑ No ❑ NA <br /> al least 6" (same as pipe diameter Yes ❑ No ❑ NA I <br /> NCE ; ` <br /> visible and protected from damage Yes No ❑ NA ❑ <br /> free firom excessive vegetation Yes No ❑ NA ❑NEOUS : <br /> Permit drawing represents actual location of well Yes ® No ❑ <br /> Permit drawing suificieni to locate well Irl future Yes Q IN ❑ li `no' is selected, a_tach an accurate map to permit <br /> Photograph taken and attached to record Yes L1 No ❑ <br /> OTHER; <br /> Comrnd`nts : <br /> E <br /> l r <br /> Inspected By : � i i_ . t : j )���� (1 Title: C , t / 1 ► U 1h III <br /> Received 13y : _ Dale: <br /> � u � � nn <br />