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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.sigov.orq/ehd <br />PUMP INSPECTION CHECK LIST <br />Address: <br />+441 Pt001 PiVe. Sc cot, CA Clc..-1,4 <br />Permit#: <br />VQP 00?)cicil, i, <br />Inspection Date: <br />(r' I ci I l'i <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes a No NA <br />Casing extends at least 12" above grade Yes [77( No NA <br />Casing extends at least 1" above pedestal Yes No LII NA I I <br />Free of cracks/contiguous with annular seal Yes LII No NA C'ccles -c.N1 \-; a-i,k-ect <br />Graded to allow drainage away from casing Yes No Ft NA LiiVt>de,-,t-ci‘ is \,C-i-ed. wciAey way drain <br />'‘'''A-C, SANITARY SEAL: ',A1 eit <br />Well is sealed between pump and casing Yes [' No NA <br />Seal between all pipe columns and casing Yes No NA <br />Sounding tube/air vents sealed properly Yes E/ No LII NA <br />Chlorination port available and sealed properly Yes E 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 a No NA <br />Adequately installed check valve or BFP device Yes FA No 7 NA r---1 <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes I i No NA Er <br />Air gap of at least 6" (same as pipe diameter) Yes LII No NA fl <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 LIII No <br />If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes FT No 7 <br />Photograph taken and attached to record Yes ErNo <br />OTHER: <br />Comments: <br />C.;eyylent \-VO- esi-0,1 k \-CA-eck on "W\e 6 g‘TI-- (5C-..Ve- 4:) *ne purflp. '-init. v. r•c-As e3 reka.c_CA <br />0 <br />'VD CM% ckrv dirCl'%'00.Cae Ci.v.i0, --erver‘ *le ca&rno. <br />Inspected By: 6cP5-1.-Ifi",( S•Aeo-A-Crn Title:EA .ZiCIA-. <br />Received By: Date: <br />EH-4200- 8/31/2015