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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:www.slgov.orq/ehd <br /> PUMP INSPECTION CHECK LIST _ <br /> Address Permi : In cti�Date: <br /> Z D I c cls- Lrn16c„J on Z <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements <br /> Recommendations <br /> CEMENT PEDESTAL: I <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes ® No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes V No ❑ NA ❑ <br /> Casing extends at least 1" above pedestal Yes 2 No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes1z No ❑ NA ❑ <br /> Graded to allow drainage away from casing lYesVjNoE1 NA ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes V No ❑ NA ❑ <br /> Seal between all pipe columns and casing Yes ® No ❑ NA ❑ <br /> Sounding tubelair vents sealed properly Yes ❑ No ❑ NA 56 <br /> Chlorination port available and sealed properly YesjZ ,No0 ,NA0 <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 01 No ❑ NA ❑ <br /> Adequately installed check valve or BFP device Yes V No ❑ NA ❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution systemlag flood irrigation <br /> fi-om domestic supply) Yes ❑ No ❑ NA U- <br /> Air gap of at least 6" same as pipe diameter) Yes ❑ No ❑ NA <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes 2 No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes No ❑ <br /> Permit drawing sufficient to locate well in future Yes Rr No ❑ If'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes LZ No ❑ <br /> OTHER: _ <br /> Comments: - I <br /> Inspected By: Lam.. SD Title: <br /> Received By: Date: <br /> Cu n�nn <br /> pi� i�naF <br />