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EWRONMENTAL HEALTH UEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95206-6232 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Web:www.slgov_org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: it e - <br /> �9, 677n ate:M1 LTV /J �D b ! b ,N .-J,�� [ � lO <br /> ParameterlStandard Meets SJG Standards? Com ments/Measurements/Recommendations <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 1v 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 &Z No ❑ NA❑ <br /> Sounding tubelair vents sealed properly Yes ❑ No ❑ NA d <br /> Chlorination port available and sealed properly Yes [j 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 No ❑ INA❑ _ <br /> Adequately installed check valve or BFP device Yes No ❑ INA ❑ <br /> No cross connections (e)L 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 ❑ NA <br /> !!MAINTENANCE: <br /> We11/Pump visible and protected from damage Yes V No ❑ NA❑ <br /> VVell/Pump free from excessive vegetation Yes INoo NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes No ❑ <br /> Permit drawing sufficient to locate well in future Yes L2 No ❑ if`no'is selected, attach an accurate map to permit <br /> !Photograph taken and attached to record Yes [I No ❑ <br /> OTHER: <br /> Comments: <br /> (V) cv�C/b 4� <br /> respected By; Cu- J u Title: 11f'�di <br /> deceived By: Date: <br /> =u nonn <br />