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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.sogov.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Permit#: Inspection Date: <br /> ,335 N. Pce t Ave . k- GPr - 15 W 3<1 812-G /+-i <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) YesNo ❑ NA ❑ <br /> Casingextends at least 12" above rade Yes o E] NA ❑ <br /> Casingextends at least 1" above pedestal Yes No ❑ NA ❑ <br /> Free of cracks/contiguous with annular seal Yes �eNo__ <br /> o ❑ NA ❑ <br /> Graded to allow drainage awayfrom casingYes ❑ NA ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes No ❑ NA ❑ <br /> Seal between all pipe columns and casing Yes E2"' No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yes No ❑ NA ❑ <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 W f\1 aye 60m-P\e -t-ap put <br /> check valve or within 3' of well head Yes L—Qra No I NA ❑ %n c Pfe c Dec*-r6t4 `s Ott –+ <br /> Adequately installed check valve or BFP device Yes No ❑ NA ❑ <br /> Any cross connections? (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No ❑ I NA 12/ <br /> Air gap of at least 6" (same as pipe diameter) jYesF1 No ❑ NA <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes No ❑ NA ❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes Er 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: <br /> No e1e c kT' c,-1-�� yep Wail pu- � ekec�k'C1-1 y 7r <br /> and Pu-�- Qn Same\e -�cc(� a�'-kear e,12c�r�cY-�y Qs <br /> Inspected By: Title: t} <br /> Received By: Date: <br /> EH-4200- 8/31/2015 <br />