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Y 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.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: A ` _ perm : � Inspe tion aye: <br /> v 1w� 9 <br /> ParameterlStandard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes Q No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes No ❑ NA❑ <br /> Casing extends at least 1" above pedestal Yes 0 No ❑ NA❑ <br /> Free of crackslcontiguous with annular seal Yes ® No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes Q 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 [V No ❑ NA❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑ NA ( <br /> Chlorination port available and sealed properly Yes E2 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 Q No ❑ NA❑ <br /> Adequately installed check valve or BFP device Yes Qj 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 ❑ NA M <br /> MAINTENANCE: <br /> Well/Purnp visible and protected from damage Yes [ No+ONA ❑ <br /> Well/Pump free from excessive vegetation Yes [✓T No ❑ <br /> MISCELLANEOUS; <br /> Permit drawing represents actual location of well Yes Q No ❑ <br /> Permit drawing sufficient to locate well in future Yes © No ❑ lf'no'is selected,attach an accurate map to permft <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER: <br /> Comments: <br /> Inspecfed By: a" S- Title: <br /> Received By: Date: <br /> =u n'3nn <br /> nevi rOn�G <br />