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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.sigoy.orq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: pamnitR: Inspection Date: <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal 2'x2'x4" minimum Yes ET No ❑ NA❑ <br /> Casingextends at least 12" above rade Yes E] No g NA❑ Y'xd' <br /> Casingextends at least 1" above pedestal Yes [,t No El NA❑ <br /> Free of crackslconti uous with annular seal Yes [A No <br /> El <br /> ❑ <br /> Graded to allow drainage awayfrom casin Yes No E] NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes 9 No ❑ NA ❑ <br /> Seal between all pipe columns and casing Yes [.l No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yes [2 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 N No ❑ NA ❑ <br /> Adequately installed check valve or BFP device Yes Eg No ❑ NA ❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic suppI Yes ❑ No [f] NA El <br /> Air gap of at least 6" same as pipe diameter Yes ❑ No ❑ NA <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage lYes Q INo ❑ INA ❑ <br /> Well/Pump free from excessive vegetation lYes M INo ❑ INA ❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes Q No ❑ <br /> Permit drawing sufficient to locate well in future lYes Q No ❑ Ivnd is selected,attach an accurate map to permit <br /> Photograph taken and attached to record lyes No ❑ <br /> OTHER: <br /> Comments: <br /> cam..-r.,,4- prde-xj�( / <br /> Inspected By: 10WY&Att, Title: �c'l ' <br /> Received By: Date: <br /> E1+4200- 0/31 ROiS <br />