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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95206-6232 <br /> Telephone: (209) 468-3420 Fax. (209)468-3433 Web;www.sjgov.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address, ^ Perm Inspegfion qa� <br /> i-1 C � M , CC E � STVC L 7vnl S p D-7�o7 10 9 <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes ❑ NON NA❑ ?.n2 X 2 <br /> Casing extends at least 12" above grade Yes k? No ❑ NA ❑ <br /> Casing extends at least 1" above pedestal Yes Q No [j ' NA❑ <br /> Free of cracks/contiguous with annular seal Yes No ❑ NA ❑ <br /> Graded to allow drainage away from casing Yes hZ No ❑ NA ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes D 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 V 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 V No ❑ NA ❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No ❑ NAW <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA EV <br /> MAINTENANCE: <br /> Well/Pump 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 JZ 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 /> C'.omrnents: <br /> C _e <br /> Inspected By: OU, SQ _ Title: L � 1S <br /> Received By: Date: <br /> cu n,)nn <br /> aoa zona G <br />