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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: [1 // / /� [I- Inspection ate: <br /> '✓ i fA � I` Imo'� (�4T Q0? PerrnQ:O D � � T 0 a6 l <br /> Parameter/Standard Meets SJG Standards? CommentsliVle� ments/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x21x4u minimum) Yes No❑ INA❑ <br /> Casing extends at least 12" above grade 1YesFjfNoE1ffNAM <br /> Casing extends at least 1n above pedestal YesQ INo ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes [0 INo❑ NA❑ <br /> Graded to allow drainage away from casing JYes 9-[No ❑ I NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing IYes 52 INoXE <br /> Seal between all pipe columns and casing Yes [I' No <br /> Sounding tubefair vents sealed properly Yes No Chlorination port available and sealed roperly Yes ❑ No <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 E] NA <br /> Adequately installed check valve or BFP device Yes 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 ❑ No❑ NA U <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes KZ I No ❑ INA❑ <br /> MISCELLANEOUS. <br /> Permit drawing represents actual location of wellAyes <br /> No ❑ <br /> Permit drawing sufficient to locate well in futureNo ❑ If`ne is selected,attach an accurate map to permit <br /> Photograph taken and attached to recordNo❑ <br /> OTHER: <br /> Comments: - <br /> eek CAU+1*q C- Vim; - ,�.,�,. r� ��.�C;I <br /> Cmc, t/) CA L,GLY C k) k U t Lary• Y'W`^' <br /> inspected Sy: l Title: <br /> lReceived 183y: Date.: <br /> =u n�nn <br />