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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East HazeIton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigovorg/ehd <br />PUMP INSPECTION CHECK LIST <br />Address:,,Permit#: <br />-)' Cl'' ei3L-C? LOLi-' C <br />Inspection Date: <br />i <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes E' No NA <br />Casing extends at least 12" above grade Yes I-11 No n NA LII <br />Casing extends at least 1" above pedestal Yes IT1 No LI NA LII <br />Free of cracks/contiguous with annular seal Yes M-- No LI NA LII <br />Graded to allow drainage away from casing Yes 17 No LI NA LI <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes 171 No NA LI <br />Seal between all pipe columns and casing Yes Fl No LI NA LI <br />Sounding tube/air vents sealed properly Yes 1-1' No LI NA LI <br />Chlorination port available and sealed properly Yes Ff No LI NA LI <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 gf No LI NA LI <br />Adequately installed check valve or BFP device Yes v No LI NA LI <br />Any cross connections? (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes LI No LI <br />. <br />NA 171 <br />Air gap of at least 6" (same as pipe diameter) Yes LI No LI NA Fr <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes i-Fi No LI NA LI <br />Well/Pump free from excessive vegetation Yes FT No LI NA LI <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes Er, <br />Yes n No LI <br />No If no is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future <br />Photograph taken and attached to record Yes Er No LI <br />OTHER: <br />Comments: <br />Inspected By: .--( A ('!, S c Lci-el c., 1 4,-.1 , -- Title: Glq- Atrey' c,,, A <br />Received By: Date: Ili qni, I 2,k1Z, \ <br />EH-4200- 8/31/2015