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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.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Permit#: 75ia6/o <br /> nspection Date: <br /> 10101 muc n k �5�i5 W 99� <br /> Parameter/Standard __FMeets 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 ❑ NA ❑ <br /> Casing extends at least 1" above pedestal Yes [j'' No ❑ NA ❑ <br /> Free of cracks/contiguous with annular seal Yes ❑' No ❑ NA ❑ <br /> Graded to allow drainage away from casing Yes a No ❑ NA ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes EZ No ❑ NA ❑ <br /> Seal between all pipe columns and casing Yes 2' 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 <br /> check valve or within 3' of well head Yes ❑ No ❑ NA 0 <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 NA ❑ <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 [Z' No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes Ea' No ❑ NA ❑ <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 a No ❑ <br /> OTHER: <br /> Comments: <br /> pumv qs 1i��t-c�l� . <br /> COYLY A G"�t7 SGI�f� t0 ��-e C`L bct C <br /> FroPer}� own era dc� r,cr� know whcc� pes `�� PumP <br /> -to 6e O a c-eA <br /> Inspected By: S CV% Title: [✓� <br /> Received By: Date: <br /> EH-4200- 8/31/2015 <br />