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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.sigov.ora/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: j, C / P r it# �� , lnspec on te: <br /> G� ��D( I�1 P 6 0 <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT 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 V above pedestal Yes No ❑ NA ❑ <br /> Free of cracks/contiguous with annular seal Yes No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes [) No ❑ NA ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes No ❑ NA❑ <br /> [Seal between all pipe columns and casing Yes No ❑ NA❑ounding tube/air vents sealed properly Yes ❑ No ❑ NA <br /> hlorination port available and sealed properly Yes No ❑ NA❑AMPLE 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 /> Adequately installed check valve or BFP device Yes No ❑ NA❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No❑ NA. <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ INA FA <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damageYes No ❑ NA F]Well/Pump free from excessive vegetation Yes No F-1NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes No ❑ <br /> Permit drawing sufficient to locate well in future Yes No ❑ If-'no'-,is selected,attach an accurate map topermit <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER; <br /> Com nts; <br /> 0(4 <br /> nspected By: r0j JA Title: n <br /> Zeceived By: Date: <br /> cu n�nn <br />