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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: G <br /> 9q rZJ L)t/ lb� Pe �, r Ins e�nDate: <br /> S t f 1 <br /> Parameter/standard Meets SJC Standards? Comments/measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4° minimum) Yes No[j NA❑ <br /> Casing extends at least 12'above grade Yes [7� No ❑ NA❑ <br /> Casing extends at least V 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 Yes No❑ NA❑ <br /> Seal between all pipe columns and casing Yes [l No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No W NA❑ <br /> Chlorination port available and sealed properly Yes 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[/f NA❑ <br /> Adequately installed check valve or BFP device Yes ❑ No NA❑ ;, „ S-ih <br /> ' No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No❑ NA Q1 <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ i [vj' <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes 0 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 sLi f[cient 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 No ❑ <br /> OTHER: <br /> Comment <br /> n <br /> Inspected By: ate„ Tit[e: .(J f ( l- <br /> Received By: 7 <br /> Date- <br /> =u n'Inn <br />