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SAN JOAQUIN COUNTY <br /> ENVIRONMLN VAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.siqov.orgLehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: <br /> CC D I U Permit#: ^ �t fj Inspection Date: <br /> 9 I C COY'1',l�t;� <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> F <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) f1N <br /> NA ❑ <br /> .Casingextends at least 12" above rade NA ❑ <br /> Casing extends at least 1" above pedestal NA ❑ <br /> Free of cracks/contiguous with annular seal NA ❑ <br /> Graded to allow drainage awayfrom casingNA ❑ <br /> SANITARY SEAL: <br /> Well is sealed betweenpump and casing Yes 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 Yes ff 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 ❑ <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 ur <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 No ❑ <br /> °ermit drawing sufficient to locate well in future Yes No ❑ if'no'is selected, attach an accurate map to permit <br /> 'hoto raph taken and attached to record Yes No ❑ <br /> tTHER: <br /> omments: <br /> Qo-. <br /> By: ` Title: <br /> 1 By: Date: p v <br /> EH-4200- 8/31/2015 <br />