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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPART MiENT <br /> 1868 East Hazelton. Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209) 468-33420 Fay., (209) 468-3433 Web:wwN.sjgov.,or /eh-d <br /> q_ <br /> PUMP INSPECTION CHECK LIST <br /> Address: Perniit*: Insp/ectiorvDate: <br /> Parameter/Standard (Meets SJC Standar ? Corti ments/Meas urer�entsy <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dim_=nsions of surface seal (2'x2'x4' r I NA L21 <br /> Casing extends at least 12"' above grade IYes No EI INA D 1 <br /> i <br /> Casing extends at least V' above pedestal I YeSE,'] N oEj 11 NA [:1 <br /> Free of cracksl'cqnt u2us with annular sea! IYes D NoD i <br /> I NAE:1 <br /> Graded t.- allow drainage a�yay fr IYes E No F.1 <br /> casing INA DI <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes NAEJ <br /> Sea] between all pipe columns and cas'!rg Yes r- INo F L I <br /> INA <br /> Sounding tube/air vents sealed properly Yes El I No E] I N A-E_7] <br /> 1-hlorination port aV21fl2ble and sealed properly 'Yes g.j INo 0 INA <br /> SAMPLE TAP AND BACKFLOVV PREVENTION: <br /> Non-threaded sample tap between vvell head and] <br /> check valve or within 3' of well head I Yes.E] No [] INA 0 <br /> Adequately installed check valve or BFP device Yes El' No F� NA E:1 <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution systemlag flood irrigation <br /> lrom domestic supply) �Yes No E NAF <br /> Air gap of at least 6" (same as pipe diameter) Yes N o.Z] NA <br /> MAINTENANCE: <br /> kNell/Pump visible and prctected from damage Nes 7, No 0 N <br /> VVellIPump fr-elcrom excessive vegetation _LyesL No F� NA <br /> MISCELLANEOUS: <br /> Permit dra in represents actua ocat on of wel Yesg, No ...-! <br /> Permit drawing sufficient to locate well .in future Yes F/_1 No P lf,no'is selected,attach an accurate rnap to cormit <br /> Ph-otogr ph taken and attached to record Yes Mo <br /> OTHER:- <br /> Co� <br /> Title: <br /> lnspecteL�_yl_17 <br /> Received BV: ------- <br /> ="l A)t.,l <br />