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SAN JOAG UIN.CoUtdTY <br /> E tiviRONMENTAL HEA01FI DEPARTMENT <br /> 1868 East Hazelton.Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 fax: (209)468-3433 Web:ww%v.sjgov.orq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: CQPermitg: tns ectlon ate: <br /> ParameterlStandard Meets SJC Standards? Comments/Meas urem en€s/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal 2'x2'x4°minimum Yes [2 j NOQ 'NA Q <br /> Casing extends at least 12' above grade Yes V No ❑ NA❑ --� <br /> sing extends at least 1" above pedestal Yes No❑ NA <br /> 17 <br /> Free of cracks/contiguous with annular seal Yes No F-1 ❑ <br /> Graded to allow drainage away from casin Yes { No ❑ NA Q <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes...W No❑ NA❑ <br /> Seal between all pipe columns and casing Yes ®' No❑ NA❑ <br /> Sounding.tubelair vents sealed properly Yes j_( No ❑ 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 No 17 NA❑ <br /> Adequately installed check valve or BFP device Yes No❑ NA❑ _ <br /> No cross connections (ex. chemical feeders <br /> hooked to distribution system/' flood irrigation <br /> from domestic sup ly Yes ❑ No Q NA <br /> Air gap of at least 6" same as pipe diameter) Yes ❑ No❑ NA L <br /> MAINTENANCE: <br /> 11VelG'Pump visible and rotected from damage Yes No❑ 'NA❑ <br /> WeI1/Pump free from excessive vegetation Yes No Q NA❑ <br /> MISCELLANEOUS: <br /> Permit drawin represents actual location of well Yes [�2!No ❑ <br /> Permit drawing sufficient to locate well in future Yes Nc ❑ t `no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes No❑ <br /> OTHER: <br /> Comments: <br /> r <br /> Inspected B Title: f 1)j j 1 g s , <br /> Received By: nate: <br /> cu n�nn <br />