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SAN JOAQUIN COUNTY <br /> ENVIRON- rA N IA1 HFALTH DEPAR f MF.NT <br /> I 868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209;468 3420 Fax:(209)468-3433 Web:yro v.si4ov.orufohd <br /> PUMP INSPECTION CHECK LIST <br /> addre Q Q D �y <br /> ! ro l 1 r� I r 1 f{7 P�I Q C>3, !7f� irtspe�on D e; <br /> Paramoter/Standar Meets SJC Standards? <br /> CommentslMeasu Im�'fC <br /> Recommendations <br /> CEMENT PEDESTAL: _ <br /> I)imensions of surface seal (2WW" Yes m No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes 2 No❑ NA y <br /> Casing extends at least 1"above pedestal Yes [�' No [I NA ❑ <br /> Free of cracks/contiquous with annular seal Yes Q No j] '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 QENO <br /> NA L1 <br /> Seal between all pipe columns and casing _ Yes NA ❑ _ <br /> Sounding tubelair vents sealed prod eriy Yes❑ No_❑ NAFi <br /> Chlorination port available and sealed properly Yes Ei2r 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 RFP device Yes � No El IN <br /> ❑ <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 U NA <br /> MAINTENANCE: <br /> Well/Pum vp isible_and protected from damage 'Yes No(� NA❑ <br /> WelffPurnp free from excessive vegetation I Yes 'No LJ j NA Q <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of weal Yes R1 No❑ <br /> Permit drawing sufficient to locate well in future Yes No ❑ lf'r:o'Is sPlacted,attach an accurate map to pormi° <br /> Photoqraph taken and attached to record Yes No❑ _ <br /> OTHER: <br /> Comments: <br /> Inspected By; YO.AV fjSt — - 7'(tle � i IS <br /> Rccelved 8 : -- — Date. <br /> cu 4)nn <br /> O FJa MilIAL <br />