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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.siAov.om/ehd <br /> PUMP INSPECTION CHEM{ LIST <br /> Address: Pe r ' ,+ Q n <br /> LI—� T�'�� ' 1 L : ����� lnsp on ate: <br /> ParameterlStandard C\ Meets SJC Standards? CommenfislMeasurementsf <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes ❑ No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes ❑ No ❑ NA❑ <br /> Casing extends at least 1" above pedestal Yes ❑ No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes ❑ 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 9 No ❑ NA ❑ <br /> Seal between all pipe columns and casing Yes [Z No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑ NA <br /> Chlorination port available and sealed properly Yes U 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 aIle t l <br /> ❑ No Yj NA❑ ,� urcl het D <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 ❑ NA[2 <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes kZ iNoo NA❑ <br /> Well/Pump free from excessive vegetation Yes 2 No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes Q No ❑ <br /> Permit drawing sufficient to locate well in future Yes L 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 /> SGS�1 l l - lY ' ��11�c� �� �„� f � �,,�, r tJ P l� � ?6 0 <br /> Inspected By: E2 Id rJS-0 Title: ,qSJrs <br /> Received By: Date: <br /> cu .conn <br />