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x SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 9 868 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• a <br /> Insp ctio Date: <br /> F�Eb ►c k 2b �� pd P , .a 038$ <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> . - 1 l 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 © No ❑ NA❑ <br /> Casing extends at least 1" above pedestal Yes[Z No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes No ❑ N <br /> No E] NA F1A[:1 ° <br /> Graded to allow drainage away from casing Yes <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 tube/air vents sealed properly Yes ❑ No ❑ NA <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 U TEDNA <br /> ❑ <br /> Adequately installed check valve or BFP device Yes ❑No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic sup ly) Yes ❑ <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA[✓� <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes 12 No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes_V No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes 12 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 /> f1 p � J��YI`1/� �(h <br /> Inspected By: S 0 rile: <br /> Received By: Date: <br /> cu norm <br />