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Date: <br />Title: ci 3; c4-144,14" <br />/ 12-C LI <br />Inspected By: fr etc) ( 62-6-4-i, t. <br />Received By: <br />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: .7 .;z <br />Permit#: <br />c I i I <br />Inspection Date: <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes 2 No El NA 0 <br />Casing extends at least 12" above grade Yes No El NA 1-1 <br />Casing extends at least 1" above pedestal Yes No El NA El <br />Free of cracks/contiguous with annular seal Yes 2 No 2 NA 2 <br />Graded to allow drainage away from casing Yes FT No El NA 2 <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes ID No El NA LII <br />Seal between all pipe columns and casing Yes No El NA 2 <br />Sounding tube/air vents sealed properly Yes E No El NA LII <br />Chlorination port available and sealed properly Yes LIV No El NA 0 <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 NoEl NA 0 <br />Adequately installed check valve or BFP device Yes 2 NoEl NA <br />Any cross connections? (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes 2 No El NA[ <br />Air gap of at least 6" (same as pipe diameter) Yes 2 No El NAEiY <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes 0 No El NA 0 <br />Well/Pump free from excessive vegetation Yes NoEl NA LII <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes EI• No 111 <br />If no is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes LII No El <br />Photograph taken and attached to record Yes 12 No El <br />OTHER: <br />Cornments: <br />EH-4200- 8/31/2015