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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.siclov.org/ehd ; <br /> PUMP INSPECTION CHECK LIST <br /> Sdressnn _ n <br /> V V �� ,Q 1 f�/ Permif#: Inspection Date: <br /> Parameter/Standard Meets SJC Standards? / Com e /Me surements/ <br /> ommendations <br /> GEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes No ❑ NA <br /> Casing extends at least 12" above grade Yes No ❑ NA <br /> Casing extends at least 1" above pedestal Yes R No ❑ ❑ <br /> Free of cracks/contiguous with annular seal Yes No ❑ A ❑ <br /> Graded to allow drainage away from casing Yes No , <br /> SANITARY SEAL: f <br /> Well is sealed between pump and casing Yes k ,No ❑ <br /> Seal between all pipe columns and casing Yes No NA <br /> Sounding tube/air vents sealed properly Yes r] 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 o NA ❑ `S - I` <br /> Adequately installed check valve or BFP devic Y s No ❑ NA <br /> No cross connections (ex: chemical feeders `r <br /> hooked to distribution system/ag flood irrigati <br /> from domestic supply) Yes ❑ No ❑ NA'' <br /> Air gap of at least 6" (same as pipe diameter) \ s ❑ No ❑ NA <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No,❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual f atio of well Yes No ❑ <br /> Permit drawing sufficient to locate el future Yes No ❑ 1 'no'is selected, attach an accurate map to permit <br /> Photograph taken and attach o re ord Yes No ❑ <br /> OTHER: <br /> Comments: I <br /> ej-D <br /> 40 4-ft <br /> 1 <br /> t. <br /> 1 <br /> J <br /> I <br /> nspectedy: Title: ,r'lP; <br /> y: Date: <br /> F-u n�nn <br />