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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.sigov.orq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: PerInspection ate: <br /> i1 w lir4ri R� `, S4':-)0 136 ` 1 it toe) <br /> Parameter/Standard Meets 5JC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) IYes No ❑ NA❑ <br /> Casing extends at least 12" above grade JYes 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 IYes 2 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[1" <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❑INA &Z <br /> Adequately installed check valve or BFP device Yes No ❑ NA❑ r ra vi <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 W No❑ NA❑ <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes M No ElNA❑ <br /> Well/Pump free from excessive vegetation Yes V No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes No ❑ <br /> Permit drawing sufficient to locate well in future Yes iNo ❑ �]Vno'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER: <br /> Comments: <br /> Inspected By: ,S � Title: <br /> Received By: d. Date: <br /> cu AOnn <br />