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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.siqovorq/ehd <br />PUMP INSPECTION CHECK LIST <br />Address: <br />(-(' ci; cs? 1._,' • C,'ci k /4 Z c, e <br /> <br />...,4 ) , C4-4.r2 it ..) <br />Permit#: <br />(-k- I-2 c r- ( i 7 (, <br />Inspection Date: <br />lit / 24-,', 1 <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes R No NA <br />Casing extends at least 12" above grade Yes 111 No NA 7 <br />Casing extends at least 1" above pedestal Yes a No NA LI <br />Free of cracks/contiguous with annular seal Yes NI No LI NA LI <br />Graded to allow drainage away from casing Yes No LI NA LI <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes No LI NA LI <br />Seal between all pipe columns and casing Yes ID No LI NA LI <br />Sounding tube/air vents sealed properly Yes v No LI NA LI <br />Chlorination port available and sealed properly Yes MI 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 el No LI NA LI <br />Adequately installed check valve or BFP device Yes No LI NA LI <br />Any cross connections? (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from dcmestic supply) Yes No LI NA 11 <br />Air gap of at least 6" (same as pipe diameter) Yes LI No LI NA <br />MAINTENANCE: 1 <br />Well/Pump visible and protected from damage Yes El No LI NA LI <br />Well/Pump free from excessive vegetation Yes No LI NA LI <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes 1-"" No LI <br />If no is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes F1 No LI <br />Photograph taken and attached to record Yes fl- No LI <br />OTHER: <br />Comments: <br />Inspected By: 1. , . -4 -4. i . e Title: 1-- <br />Received By: Date: ii (2.C / i <br />EH-4200- 8/31/2015