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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 /> _ <br /> PUMP INSPECTION CHECK LIST <br /> Address- Date:O V�/ �� L,�0 --� Per i Inspectio <br /> 77 3 ©0 68 _ <br /> ParamC o m n7 ents/Measurements/efierlSfiandard Meets SJC Standards? Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes V No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes [,Z No ❑ NA ❑ <br /> Casing extends at least 1" above pedestal Yes ❑ No ❑ NA ❑ ' <br /> Free of cracks/contiguous with annular seal Yes 2 No ❑ NA ❑ <br /> Graded to allow drainage away from casing Yes Q No ❑ NA ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes Q No ❑ NA ❑ <br /> Seal between all pipe columns and casing Yes ❑✓ No ❑ NA ❑ <br /> Sounding tubetair vents sealed properly Yes ❑ No ❑ NA <br /> Chlorination port available and sealed properly Yes Q 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 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 ❑ I No ❑ NA [g <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes q No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes �j No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes ® No ❑ <br /> Pen-nit drawing sufficient to locate well in future Yes ® No ❑ it'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes W No ❑ <br /> OTHER: <br /> Comments: <br /> lhs �c � <br /> I <br /> Inspected By: Gl.b� J�(7 -- ------- Title: S1�s <br /> Received By: Date: <br /> �u nonn <br /> aizai�nr_ <br />