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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.s'gov.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Permit#: Ins ection Date: <br /> ab1 f_ 5 W CC..`4(,c� z ICA �zc I iq <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal 2'x2'x4" minimum Yes a No ❑ NA ❑ <br /> Casing extends at least 12" above grade Yes []' No ❑ NA ❑ <br /> Casing extends at least 1" above pedestal Yes a No ❑ NA ❑ <br /> Free of cracks/contiguous with annular seal Yes a 1No ❑ NA ❑ <br /> Graded to allow drainage away from casing Yes No ❑ NA ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes [a' No ❑ NA ❑ <br /> Seal between all pipe columns and casing Yes No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yes [ No ❑ NA ❑ <br /> Chlorination port available and sealed properly I Yes 1 No 1 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 a No ❑ NA ❑ <br /> Adequately installed check valve or BFP device Yes Q' No ❑ NA ❑ <br /> Any cross connections? (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No ❑ NA a <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes a No ❑ NA ❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes allo ❑ <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: <br /> ►�c c+i cc cid n��ed owner c ih e Ch 10� ncz��o r1 pug'�, sc�►d sine W\1 <br /> �n�Cr M CUk'7KQCjr iC: �iX NC12 PYc;h1Qm <br /> Inspected By: "sy n S y Title: �cS A-n AT <br /> Received By: Date: <br /> EH-4200- 8/31/2015 <br />