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SAM JOAnaum (,-.OUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Tefepho.,79:(209) 468-3420 F'ax., (209)468-3433 I[Veb. vAtV-w.sigov,oLg/ehd <br /> PUMP INSPECTiON CHECK LIST <br /> Address: P e rm,I it.: Inspection Date: <br /> Parameter/Standard Meets AJC Standards? Colit til etitsift4easi-,rc-mencc-'I <br /> Recommeiidatioris <br /> CEMENT PESES—UkL2 <br /> Dimensions Of Surface seal (2'x2'x4" minimum)—Yes No NAEJ <br /> Casing extends at least 12' above grade Yes No ❑ NAE] <br /> Casing extends at least 1" above pedestal Yes NoEl NAE] <br /> Free of cracks/contiguous with annular sea.] Yes NoFla NAF❑I <br /> Graded to allow drainage away from casing Yes [j INo 0 INA❑ <br /> SANITARY SEAL: <br /> IWell is sealed between PLIMP and casing 11 Yes INo <br /> JY —1 INAE] <br /> Y <br /> Seal between all pipe columns and casing e INoE1 NAE:1 <br /> Yes <br /> Y No D NAE] <br /> Sounding tube/air vents sealed properly I Yes <br /> 1'.., <br /> Chlorination port available and sealed properly Yes <br /> I Yes I No ❑ I NA <br /> SAMPLE TAP AND BACKIFLOW PREVENTION: <br /> Non threaded sample'Lap between well head and <br /> check valve or vvithin 3' of well head IYes No ❑ �NA❑ <br /> Adequately installed check valve or BFP device Yes LA No 0 INAE] I <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution systern/ag flood irrigation <br /> from orn domestic supply) YesE] No al NA <br /> -Air cap of at least 6;' (same as pipe diameter) Yes NA [4T— <br /> MAI lq TLE NA N C E <br /> Well/Pump visible and protected from damage AYes .N o ❑ NA <br /> Yes <br /> MellIPUrnp free from excessive vegetation No F1 INA ❑ <br /> J SCELLAtiEOUS: <br /> i <br /> Permit drawing represents actual location of well IYes INoE1 <br /> Permit drawing KlffiCient tO locate well in future If'no'is selected.attach an accurate map to permit <br /> I Yes 0—0 <br /> Photograph taken and attached to record I e b I No0 <br /> OTHER: <br /> Commerits: <br /> Irispected By: x" Title: im <br /> Received By: Date: ------ <br />