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T ; 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 I JST <br />Address: <br />L� 54Ck <br />Parameter/Standard Meets SJC Standards? <br />Me: <br />38,50-3 QsPe03 �. <br />Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) <br />Yes ❑ <br />No ❑ <br />NA ❑ <br />rj0 <br />Casing extends at least 12" above grade <br />Yes ❑ <br />No ❑ <br />NA ❑ <br />Casing extends at least 1° above pedestal <br />Yes ❑ <br />No ❑ <br />NA ❑ <br />Free of cracks/contiguous with annular seal <br />Yes ❑ <br />No ❑ <br />NA ❑ <br />Graded to allow drainage away from casing Yes ❑ No ❑ NA ❑ , <br />SANITARY SEAL: <br />Well is sealed between pump and casing <br />Yes M <br />No ❑ <br />NA ❑ <br />Seal between all pipe columns and casing <br />Yes V <br />No ❑ <br />INA ❑ <br />Sounding tube/air vents sealed properly <br />Yes ❑ <br />No ❑ <br />NA [ <br />Chlorination port available and sealed properly <br />Yes W <br />lNo ❑ <br />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 <br />Yes ® <br />jNo0 <br />NA ❑ <br />Adequately installed check valve or BFP device <br />Yesg <br />No ❑ <br />NA ❑ <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) <br />Yes ❑ <br />No ❑ <br />NA []' <br />Air gap of at least 6" (same as pipe diameter) <br />Yes ❑ <br />No ❑ <br />NA [a' <br />MAINTENANCE: <br />Well/Pump visible and protected from damage <br />Yes 2 <br />No ❑ <br />NA ❑ <br />Well/Pump free from excessive vegetation <br />YesO <br />No ❑ <br />NA ❑ <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well <br />Yes <br />No ❑ <br />If 'no' is selected, attach an accurate map to permit <br />Permit drawing sufficient to locate well in future <br />]Yes <br />Yes 0 <br />No ❑ <br />Photograph taken and attached to record <br />[0 <br />No ❑ <br />OTHER: <br />Comments: p <br />Cx <br />t4 0 CL ►kPw7(R S lni►-� u w•. r� �5 <br />0 <br />Inspected By: ou't �Title: <br />Received By: Date: <br />C:u AOnn <br />Qle4.1 ronq 9 <br />