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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 9868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone; (209)468-3420 Fax: (209)468-3433 Web;www.s►laov.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: o�� Perm Inspe tion Date: <br /> 4 S. CABLE �� , T� �� ov3�593 nb a3 i8 <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes KZ No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes 2 No ❑ NA ❑ <br /> Casing extends at least 1" 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 [U' No ❑ NA ❑ <br /> Seal between all pipe columns and casing Yes [' No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑ NA 9 <br /> Chlorination port available and sealed properly I Yes B' 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 ❑ 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 [2' <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes [a' No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes [Z No ❑ NA ❑ <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 to permit <br /> Photograph taken and attached to record Yes M No ❑ <br /> OTHER: <br /> Comments: <br /> 1L i S, Ce W,U� Lie(( <br /> kla l hS fia (( ,e I o,r„d Samp I <br /> Inspected By: Q,I... �ro Title: C` A-SJ t <br /> Received By: Date: <br /> cu n)nn <br /> Rv�aion aG <br />