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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 />C)411 Pi t-7 c/ 4.(r ‘/t <br />Permit#: <br />I''t ' tiC'C' iilli L <br />Inspection Date: <br />Y11/.24-if <br />I <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes FT No LII NA <br />Casing extends at least 12" above grade Yes Fl No NA <br />Casing extends at least 1" above pedestal Yes 0 No NA <br />Free of cracks/contiguous with annular seal Yes 171 No LIII NA <br />Graded to allow drainage away from casing Yes FM No NA <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes 111 No NA <br />Seal between all pipe columns and casing Yes 12 , No NA <br />Sounding tube/air vents sealed properly Yes 11 No NA LI <br />Chlorination port available and sealed properly Yes [Z No NA ri <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 V No NA LI <br />Adequately installed check valve or BFP device Yes I VI' No NA LI <br />Any cross connections? (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes No NA V <br />Air gap of at least 6" (same as pipe diameter) Yes LI No LI NA 17 1 <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes RI No Lii NA LI <br />Well/Pump free from excessive vegetation Yes E No NA LII <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes ffi No LII <br />If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes [V No <br />Photograph taken and attached to record Yes [7' No LI <br />OTHER: <br />Comments: <br />Inspected By: ci Ai\ C L .:,‘ Qa.-cc t , \ A,c 1 Title: r-17-I 4SS,(44.vt. 4 <br />Received By: Date: ''.( // l:2_1 <br />EH-4200- 8/31/2015