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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.sjgov.org/ehd <br /> Address: <br /> PUMP INSPECTION CHECK LIST <br /> 0 <br /> �• ,r Q fl-S LJ91J I ) �� Perm, Ins an Date: <br /> zK ^ SP,607607 <br /> ParameterlSfandard Meets S IC Standards? Comments/Measuremenfs/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal 2'x2'x4" minimum Yes ❑ N NA❑ Z Z <br /> Casing extends at least 12" above grade Yes No ❑ NA❑ <br /> Casing extends at least 1" above pedestal Yes FZJ No [ NA❑ <br /> Free of cracks/contiguous with annular seal Yes KZ No ❑ NA <br /> Graded to allow drainage away from casing Yesv[f 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❑ <br /> Sounding tube/air vents sealed property Yes [Z No ❑ NA❑ <br /> Chlorination port available and sealed roperly Yes ❑ No ❑ NA[1—/ <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 ❑ 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 su ly Yes ❑ No❑ NA[t� <br /> Air gap of at least 6" (same as pipe diameter) _ Yes ❑ No❑ NA Z <br /> MAINTENANCE: <br /> Well/Pum visible and protected from damage Tes No ❑ NA❑ <br /> Well/Pump free from excessive vegetation jYes0 jNoDjNA0 <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes No ❑ <br /> Permit drawing sufficient to locate well in future Yes ND ❑ lf'no'is selected, attach an accurate map to permit <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER: <br /> Com nts: <br /> Inspected By: a. / tj <br /> Received By: Date: <br /> .0 Alnn <br />