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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.siciov.orgiehd <br />PUMP INSPECTION CHECK LIST <br />Address: <br />t ij 1---‘ie CP) iiri-17-6 , / <br />Permit#: <br />L ,---',00 Vt5 -/z <br />Inspection Date: <br />boic2/ <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes Er No — NA Eli <br />Casing extends at least 12" above grade Yes 1., No 7 NA Lii <br />Casing extends at least 1" above pedestal Yes V No NA <br />Free of cracks/contiguous with annular seal Yes 1 No Eli NA LII <br />Graded to allow drainage away from casing Yes 17 No NA El <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes 51' No NA El <br />Seal between all pipe columns and casing Yes <br />_ <br />I, No NA <br />Sounding tube/air vents sealed properly Yes FIT No NA 7 <br />Chlorination port available and sealed properly Yes IT No LII 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 No NA <br />Adequately installed check valve or BFP device Yes Fq.-- No NA <br />Any cross connections? (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes El No El NA Ft <br />Air gap of at least 6" (same as pipe diameter) Yes El No El NA rcr <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes IT-- No El NA El <br />Well/Pump free from excessive vegetation Yes 7' No El NA <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes IYNo El <br />If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes /-No <br />Photograph taken and attached to record Yes 17 No El <br />OTHER: <br />Comments: <br />Inspected By: fr-c,l_c :.s: ( , , ILVL ,-- Title: ch <br />Received By: Date: <br />EH-4200- 8/31/2015