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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.sjgov.org/ehd <br />PUMP INSPECTION CHECK LIST <br />Address:A <br />41E9 L:Ve ccik.. cot i__-(t, cf)--)..ic <br />Permit#: <br />kik,p DO Cle>1.-k, <br />Inspection Date: <br />al i 119 <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes 2' No NA LI <br />Casing extends at least 12" above grade Yes P" No LI NA LI <br />Casing extends at least 1" above pedestal Yes H- No LI NA LI <br />Free of cracks/contiguous with annular seal Yes [2/ No LI NA LI <br />Graded to allow drainage away from casing Yes R-- No Lii NA LI <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes a No pi NA LI <br />Seal between all pipe columns and casing Yes F.- No NA LI <br />Sounding tube/air vents sealed properly Yes No LI NA 2/ <br />Chlorination port available and sealed properly Yes a' No 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 r7/ No NA LI <br />Adequately installed check valve or BFP device Yes Q/ No NA LI <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes No LI NA Er <br />Air gap of at least 6" (same as pipe diameter) Yes LI No LI NA F' <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes r/ No LI NA LI <br />Well/Pump free from excessive vegetation Yes LI No 7 -NA LIlo 0 rub, deb r is Oro ucv-i Wu, <br />MISCELLANEOUS: Nivek%)110-np, ckear de\z.e-is -CI-0;n s.,;_..r...--,-,,..1 vvi...V rsej Otreri <br />Permit drawing represents actual location of well Yes <br />Yes F1/No <br />No LI <br />LI 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 177No LI <br />OTHER: <br />Comments: <br />h ‘. Inspected By: ("\6\1,r1Q 30-ever )() Title: E Vi Plst-...,ct'sk <br />Received By: Date: <br />EH-4200- 8/31/2015