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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.sjgov_orq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Permit#:' r�o�� Inspe tion Date: <br /> �7u7 �� W of IT <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes ❑ No ❑ NA ❑ <br /> Casing extends at least 12" above grade Yes ❑ No ❑ INA❑ <br /> Casing extends at least 1" above pedestal Yes ElNo ElNA❑ /` ' <br /> Free of cracks/contiguous with annular seal Yes ❑ No ❑ NA❑ Sv �' �✓� �' <br /> Graded to allow drainage away from casing Yes ❑ No ❑ NA❑ J k-t-t,,d <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes No ❑ INA ❑ <br /> Seal between all pipe columns and casing Yes Q No ❑ INA ❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑ NA EV <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 W No ❑ NA ❑ <br /> Adequately installed check valve or BFP device Yes ❑1 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) jYesE1 No ❑ INA[j;� <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage IYesjZ INoE:l NA ❑ 11 <br /> Well/Pump free from excessive vegetation IYes No ❑ INA ❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes No ❑ <br /> Permit drawing sufficient 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 /> Comments: tf <br /> . <br /> Inspected By: Ol.A, Title: `�� <br /> Received By: <br /> Date: <br /> EH-4200- 8/31/2015 <br />