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SAN JOAQUIN GOUNTY <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 LIST <br /> Address- - W o o A Y I �� 4O t '3 40 4 Sh / ltts c" n D fie: <br /> C�.CJ � � V `) <br /> Parameter/Standard Meets SJC Standards? Commenfs/Measurements) <br /> Recommendations <br /> GEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) IYesNo ❑ NA❑ <br /> Casing extends at least 12" above grade I Yes M64 No❑ INA❑ <br /> Casing extends at least 1" above pedestal Yes EA INo ❑ INA❑ <br /> Free of cracks/contiguous with annular seal Yes 9 1 No❑ NA❑ <br /> Graded to allow drainage away from casing Yes No ❑ INA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing IYes No ❑ NA❑ <br /> Seal between all pipe columns and casing Yes No❑ NA El <br /> Sounding tubelair vents sealed properly Yes ❑ No ❑ NA <br /> Chlorination port available and sealed properly Yes ❑ No ❑_ NAJR <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 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 ❑ No ❑ N <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes 56 INo ❑ NA❑ <br /> MII/Pump free from excessive vegetation Yes No ❑ INA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes I§-- Vn <br /> Permit drawing sufftcient to locate well in future Yes o'is selected, affach an accurate map to permit <br /> Photograph taken and attached to record Yes <br /> OTHER: <br /> Comments: <br /> aS.11J T qn,�' <br /> Inspected By: Q Title- h�(� F f <br /> IA <br /> Received By: jDate: <br /> cu n-nn <br />