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SAN JOAQUIN COUNTY <br /> ENVIRONMF='N rAI HEALTH DEPAR f MFNT <br /> 1868 East Hazelton Avenue,Stockton, CA 9520.5-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:vvA-:_si4ov.or_qlehd <br /> PUMP INSPECTION CHECK LIST <br /> Penni 11nColf <br /> Paramoter/Standar �lVrcpts SJC Standards? Comm entslMeasurementst <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal 2'x2'x4" rninimum Yes g No ❑ NA <br /> Casing extends at least 12" above grade Yes g No❑ NA <br /> Casin extends at least 1" above pedestal Yes [Z No [J NA❑ <br /> Free of cracks/contiguous with annular seal Yes Q No❑ NA <br /> Graded to allow drainage away from casing Yes Q No❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes L-0 No El NA <br /> Seal between all pipe columns and casing _ Yes V No 0 NA �] <br /> Sounding tube/air vents sealed properly Yes❑ No❑ NA <br /> Chlorination port available and sealed properly Yes[it 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 FZ No❑ NA <br /> Adequately installed check valve or BFP device_ Yes 9 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 ❑ I No[_]_ NA 2 <br /> MAINTENANCE: <br /> Well/Pump visible and protected from dams a Yes No❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes !No❑ NA ❑ _ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes [0 No El <br /> Permit drawing sufficient to locate well in future _ Yes No ❑ Ir`ra)'Is selwled,attach an accurate map to pcfmit <br /> Photograph taken and attached to record _ Yes [ No ❑ <br /> OTHER: <br /> Comments: - <br /> lnspectcd By: Y"kS-4 _ _ Title. <br /> Received By: _ — -- – -- Data: — <br /> =U A7nn OPJa MfnAL <br />