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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 sjgov org/ehd <br />PUMP INSPECTION CHECK LIST <br />Address: <br />113 t ( ti- rc: (i)7';'. V ied: 09 93-2 <br />Permit#: <br />44)eia 1-:-/ / 7 31 <br />Inspection Date: <br />I <br />Parameter/Standard Meets SJC Standards? Comments/Measurementdi <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes ri No LI NA LI <br />Casing extends at least 12" above grade Yes v No H NA <br />Casing extends at least 1" above pedestal Yes [71 / No H NA <br />Free of cracks/contiguous with annular seal Yes rv1 No LII NA Eli <br />Graded to allow drainage away from casing Yes rill No H NA <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes M No li NA <br />Seal between all pipe columns and casing Yes El No 7 NA <br />Sounding tube/air vents sealed properly Yes No H NA <br />Chlorination port available and sealed properly Yes 111 No H 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 H NA <br />Adequately installed check valve or BFP device Yes [11 No H NA <br />Any cross connections? (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes H No H NA 11 <br />Air gap of at least 6" (same as pipe diameter) Yes H No NA <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes FI, No H NA <br />Well/Pump free from excessive vegetation Yes No H NA <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes I-4 No <br />If 'no is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes ,r, i No H <br />Photograph taken and attached to record Yes F4 No <br />OTHER: <br />Comments: <br />Inspected By: 7'i-<,.; \L c _ 6,-<.-,.--e.-- v /is' ,..i . Title: /-:7"- <br />41 <br />Received By: Date: q/ hi zyzi <br />EH-4200- 8/31/2015