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Y 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.sjgov.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Penn' Insption qt� <br /> S u� �o� /Y1 AWT-ECA 06038? 3�- 110871111 <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> 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 W No ❑ NA❑ <br /> Casing extends at least V above pedestal Yes 2 No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes 2 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 [,�] No ❑ NA ❑ <br /> Sounding tubelair vents sealed properly Yes ❑ No ❑ NA V <br /> Chlorination port available and sealed properly Yes 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 IFV No ❑ NA ❑ <br /> Adequately installed check valve or BFP device Yes [0 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[,�] <br /> MAINTENANCE: <br /> WelVPump visible and protected from damage Yes No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes No ❑ <br /> Permit drawing sufficient to locate well in future Yes © No ❑ lf'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes No❑ <br /> OTHER: <br /> Comments: <br /> Inspected BTitle: - <br /> Received By: Date: <br /> �u <br />