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• 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: Perm ".`: InsAecfion ale: <br /> Loo ✓� s�DC/"o�J ',�v3g 1q Z ���3� <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes ❑ No W NA❑ CLI nw19L;-, <br /> Casing extends at least 12" above grade Yes Q No ❑ NA ❑ <br /> Casing extends at least 1" above pedestal Yes [Z No ❑ NA ❑ <br /> Free of cracks/contiguous with annular seal Yes © No ❑ NA ❑ <br /> Graded to allow drainage away from casing Yes [,Z/ 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 fq No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yes V No ❑ NA ❑ <br /> Chlorination port available and sealed properly Yes 2 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 R1 No ❑ NA ❑ <br /> Adequately installed check valve or BFP device Yes f Z No ❑ NA ❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No ❑ NA [+ f <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA Q <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes F;/_1 No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes [0 No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes 2 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 /> Inspected By: �'lM S 0 Title: /�• � <br /> Received By: Date: <br /> =u nonn <br /> nna1nna� <br />