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r SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone; (209) 468-3420 Fax. (209) 468-3433 Web; wwrv,sigov.org/ehd <br />PUMP INSPECTION CHECK LIST <br />Address: � � �� L� /, b I Permit : r <br />t)qV ( ^, �I geo��J-r� (-f <br />Ins , 6 <br />/ <br />Parameter/Standard <br />Meets SJC Standards? Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4U minimum) <br />Yes ' No ❑ NA ❑ <br />Casing extends at least 12" above grade <br />Yes [1Vj No ❑ NA ❑ <br />Casing extends at least V above pedestal <br />Yes [V No ❑ NA ❑ <br />Free of cracks/contiguous with annular seal <br />Yes No ❑ NA ❑ <br />Graded to allow drainage a4vay from casing <br />Yes No ❑ INA ❑ <br />SANITARY SEAL: <br />Well is sealed between pump and casing <br />Yes No ElNA El <br />Seal between all pipe columns and casing <br />Yes No ❑ NA ❑ <br />Sounding tube/air vents sealed properly <br />Yes ❑ No � NA 0 <br />Chlorination port available and sealed properly <br />iYes M lNo ❑ INA ❑ <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 ❑ No [ NA ❑ <br />valve or BFP device <br />Adequately installefsys'Lem/ag <br />No cross connectiochemical It <br />hooked to distributiflood irrigation <br />from domestic supp <br />Yes ❑ No [Z NA ❑ (;, „�`�' -S +r , <br />Yes ❑ No ❑ NA E� <br />Air gap of at least 6" (same as pipe diameter) <br />Yes ❑ I No ❑ NA 4 <br />MAINTENANCE: <br />VVell/Pump visible and protected from damage <br />esO, <br />No ❑ NA ❑ <br />Well/Pump free from excessive vegetation <br />Yes [� <br />No ❑ NA ❑ <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well <br />Yes 11 <br />No ❑ <br />No ❑ I7'no' is selected, attach an accurate map to permit <br />No ❑ <br />Permit drawing sufficient to locate well in future <br />Yes U <br />Photograph 'Laken and attached to record <br />Yes <br />OTHER: <br />Comment r <br />Inspected By: V aj„ Tide: fps <br />Received By: Date: <br />�:u nWnn <br />