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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East HazeIton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd PUMP INSPECTION CHECK LIST Address:ri i 1 C CJ Rei L ci , M q,c -2 - L 1 Permit* k> p i.,v c 54, Inspection Date: 1//21p--11 Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimenslons of surface seal (2'x2'x4" minimum) Yes 1,—,/ No NA Casing extends at least 12" above grade Yes FT No NA Casing extends at least 1" above pedestal Yes NI No NA Free of cracks/contiguous with annular seal Yes E No NA Graded to allow drainage away from casing Yes El No LII NA SANITARY SEAL: Well is sealed between pump and casing Yes No NA Seal between all pipe columns and casing Yes III No I I NA 11111 Sounding tube/air vents sealed properly Yes 11/ No NA Chlorination port available and sealed properly _ Yes LI No NA SAMPLE TAP AND BACKFLOW PREVENTION Non-threaded sample tap between well head and check valve or within 3' of well head Yes [T No NA LI Adequately installed check valve or BFP device Yes .-1 No LI NA LI Any cross connections? (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes E No NA Air gap of at least 6" (same as pipe diameter) Yes LII No 7 NA H MAINTENANCE: Well/Pump visible and protected from damage Yes No LI NA LI Well/Pump free from excessive vegetation Yes V No LI NA LII MISCELLANEOUS: Permit drawing represents actual location of well Yes Ft No LI If no is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes ,No LI Photograph taken and attached to record Yes Fl No LI OTHER: Cornments: Inspected By: rc c.v,\ c,', _I Li) (9art , 4 Kt: 7_ Title: C ,14 j Received By: Date: i ) I 2, H. EH-4200- 8/31/2015