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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.orgiehd <br />PUMP INSPECTION CHECK LIST <br />Address:, <br />:It LI Z 1'{ nit; ( (. 'e ' T \ <br />Permit#: <br />LL ,i't i. ypi - • <br />Inspection Date: <br />I 1 4 i'' :/' ` . i <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes . ' No El NA El <br />Casing extends at least 12" above grade Yes No El NA El <br />Casing extends at least 1" above pedestal Yes FT No El NA El <br />Free of cracks/contiguous with annular seal Yes s., No El NA El <br />Graded to allow drainage away from casing Yes riT No El NA El <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes Er No El NA El <br />Seal between all pipe columns and casing Yes ril-- No El NA Ill <br />Sounding tube/air vents sealed properly Yes E No El NA El <br />Chlorination port available and sealed properly Yes 1-1- No El NA El <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 Il No El NA El <br />Adequately installed check valve or BFP device Yes 1-1- No El NA El <br />Any cross connections? (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes El No El NA . <br />Air gap of at least 6" (same as pipe diameter) Yes El No El NA ii <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes ET- No El NA El <br />Well/Pump free from excessive vegetation Yes El No El NA El <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes [LYN° El <br />If no is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes TI No El <br />Photograph taken and attached to record Yes E No El <br />OTHER: <br />Comments: <br />le-- r L2& e-4 4 ali n7 t1A91 Lk; t, <br />, <br />(1 t ctil <br />Inspected By: cc f (7 (,-, 62,,..--z-, .,_: 12,:g. <br />. . <br />#i Title: <br />Received By: Date: 1/ C /2 IP 2-1 <br />EH-4200- 8/31/2015