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P 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.slgov.orq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Addresy') � Per <br /> J I (f � Ins eFtion/Date: <br /> Pararneter/Standard Meets SJC Standards? CommentslMeasurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) IYes ❑ No.[O NA❑ aX X <br /> Casing extends at least 12" above gradeYes © No ❑ NA❑ <br /> Casing extends at least V above pedestal Yes© No ❑ NA El4itiw r►�-t,+, <br /> Free of cracks/contiguous with annular seal Yes © No El ElCuti�(ir.Q, �wrr <br /> Graded to allow drainage away from casing Yes No [� NA El �x I k 4� <br /> SANITARY SEAL: VW <br /> Well is sealed between pump and casing Yes RA No ❑ NA❑ <br /> Seal between all pipe columns and casing Yes No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑ NA W <br /> Chlorination port available and sealed properly I Yes 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❑ � S <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 M <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA EZ <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes 2 No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes EZ- No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes 0 No ❑ <br /> Permit drawing sufficient to locate well in future Yes 0 No ❑ lf'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER: <br /> Comments: q <br /> LAIN t <br /> WMf � cz <br /> C� <br /> \nA stv., <br /> Inspected By: CL, Title: <br /> Received By: Date: <br /> cu nonn <br /> ani zona� <br />