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'OUNTY <br /> Ai--I J 0 A 0-U I!,! G <br /> ENIVIRONMENTIAL HEALTI-,, DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> 1 L ID <br /> To-Ifephone:(209)468-3420 F"ax: (209)4608-3433 iffeb:vvvvvv.sjqov,oI-gjehd <br /> PUMP INSPECTION CHECK LIST <br /> ddr6ss: PerniV.r PC t, <br /> Date <br /> qxlLb <br /> ParanieterlStandard Nheets SJC Standards? ConirnentsiMeasuremen'sl <br /> Recomrnend2.fions <br /> CEMENT PEDESTAL: II <br /> Dimensions of surface seal (2'x2'x4` )-ninimum)_ NAE1 <br /> Casing extends at least 12" above grade NAE1 <br /> Casing extends at least 1" above pedestal Yes j jNoE1 INAE] I <br /> Free of crFCkSICOIItigLIOUS with afflllUlar seal Yes No 0 NAEI <br /> Graded to allow drainag-e away from casing I Yes NoEl INAE] I <br /> SANITARY SEAL: <br /> Well is sealed between purnp and casing Yes JNoE:1 I NA❑ I <br /> Seal between all tYpe columns and casing Yes NoEl NAD <br /> Sounding tube/air vents sealed properly Yes No E] INA El I <br /> Chlorination poiavailable and sealed properly Yes No E JNAEJ I <br /> SAMIPLE 'FAP AND BACKFLOVUPREVETION: <br /> Non-threaded sample"MID between we'11 head and <br /> check valve or within 3' of well head Yes No ❑ NA E-1 <br /> Adequately i nstal led check valve or B FP device Yes j No El INAE] I <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution sys-Cem/ag flood irrigation <br /> frail domestic.supply) Yes I jNoE1 NAE] <br /> Air gap of at least 6:' (same as pipe diameter) I YesEl jNoE1 NA rJ I <br /> 1 MAINT11-NANCE: <br /> Well/Pump visible and protected from darnage Yes 'No ❑ <br /> NA ❑ <br /> ;Well/Pump free firorn excessive vegetation IYes L\jl No El NA [:1 <br /> 10 C E L L A N rL---0 U S., <br /> Permit drawing represents actuallocationof kivell Yes No ❑ <br /> Permit drawing sufficient'Lo locate vvell in fui-ure 1,Jes No ❑ lf'no'is selected,attach EI-I 3CCUratenlip to permit <br /> Yes <br /> Photograph taken and attached to record JNoE1 <br /> OTH HER: <br /> 'Gonirnerrts.- <br /> rz <br /> A A rk' <br /> 11-ISIDec-Led By: (Title: SSt <br /> Received Sly: Date:I <br />