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c 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.orq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address:--_— � --T ��G 1 � Perri}if. Insp cfio Dafe <br /> l��V q3 6 r �r2 j� <br /> Parameter/Standard L Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> GEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" rninimum) Yes JZ No ❑ NA❑ _ <br /> Casing extends at least 12" above grade Yes 21 No ❑ NA❑ _ �l <br /> Casing extends at least 1" above pedestal Yes © No ❑ INA ❑ <br /> Free of cracks/contiguous with annular seal Yes ❑✓ No ❑ NA ❑ <br /> Graded to allow drainage away from casing I Yes ❑✓ No ❑ NA ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes 0 No ❑ NA ❑ <br /> Seal between all pipe columns and casing Yes No ❑ NA ❑ <br /> Sounding tubefair vents sealed properly Yes ❑ No ❑ NA W <br /> Chlorination port available and sealed properly 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 WI No ❑ NA ❑ <br /> Adequately installed check valve or BFP device Yes V] 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 ❑ INo ❑ NA 10 <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes �] No ❑ INA ❑ <br /> Well/Pump free from excessive vegetation Yes R] No ❑ INA❑ <br /> MISCELLANEOUS: <br /> i <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 No ❑ <br /> OTHER: — - <br /> Comments: --- -- <br /> -e- s <br /> 42C �vlJ� GL/V�zj c -L-.,i V-e <br /> y'q <br /> Inspected By: S V Title: S <br /> Received By: Date: <br /> Cu n')nn <br /> Rn1 i0na G <br />