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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.sjgov.orq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address C Per p�Cton te:WK a <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/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 D No ❑ NA ❑ <br /> Casing extends at least V above pedestal Yes [V' No ❑ NA ❑ <br /> Free of cracks/contiguous with annular seal Yes [j� No ❑ NA ❑ <br /> Graded to allow drainage away from casing Yes Ej� 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 a No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑ NA Y <br /> Chlorination port available and sealed properly IYes 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 [v� <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 V <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes V 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 ❑ If'no'is selected, attach an accurate map to permit <br /> Photograph taken and attached to record Yes pK No ❑ <br /> OTHER: <br /> Comments: <br /> Q a � 1'rr)cry 5�.-,� � 1'jtP, <br /> P <br /> Inspected By: a't' 's to Title: I S ltq.41 <br /> Received By: Date: <br /> =u n)nn <br /> ❑naf�nI r <br />