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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> -- - - -1868-East Hazelton Avenue, Stockton,-CA 5205-6232 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sigov.org/ehd <br /> - - ---_PUMP INSPECTION-CHECK LIST <br /> Address, 0 �C / (� f� �C�Pu Pe NC) 3103�Z I0 3 'ion Date: <br /> V Parameter/Standard /V Me�e.ts1SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal 2'x2'x4" minimum) Yes E2 No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes ® No ❑ NA❑ <br /> Casing extends at least 1" above pedestal Yes [O No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes R1 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 [✓] No ❑ NA❑ <br /> Seal between all pipe columns and casing Yes [I No ❑ NA❑ <br /> Sounding tube/air vents sealed properly - Yes ❑ No ❑ NA D <br /> Chlorination port available and sealed properly Yes E3 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 V INo ❑ NA❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No ❑ NA Q <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA E91 <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes N2 No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes Q' No ❑ NA❑ <br /> MISCELLANEOUS: - <br /> Permit drawing represents actual location of well Yes U No ❑ <br /> Permit drawing sufficient to locate well in future Yes L2 No ❑ if'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes [v]' No ❑ <br /> OTHER: <br /> Inspected By: CILA, YJS 0 Title: —. J is <br /> Received By: Date: <br /> 1 A/AA/.tI1AG <br />