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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 />s A ( 6)6, , <br />Perm it#: 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 rf No Lii NA <br />Casing extends at least 12" above grade Yes v No LI NA LI <br />Casing extends at least 1" above pedestal Yes WI, No LI NA LI <br />Free of cracks/contiguous with annular seal Yes ITI No 7 NA LI <br />Graded to allow drainage away from casing Yes 7 No Eli NA Eli <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes III No LI NA III <br />Seal between all pipe columns and casing Yes 7[ No I I NA LII <br />Sounding tube/air vents sealed properly Yes 1-77 No LI NA LI <br />Chlorination port available and sealed properly Yes 171 No I-1 NA Ill <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 Fr No LI NA LI <br />Adequately installed check valve or BFP device Yes X No LI NA LII <br />Any cross connections? (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes I I No LI <br />_ <br />NA - <br />Air Air gap of at least 6" (same as pipe diameter) Yes LI No NA <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes lul No NA LI <br />Well/Pump free from excessive vegetation Yes FI No NA <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes Ill No LI <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 F-V No LI <br />OTHER: <br />Comments: <br />Inspected By: crelys t, (.j L-; azy-W.e Li'l., Title: Cii 4-(c--,; 31)-0-1, -21 <br />Received By: Date: 4ihd-t\ <br />EH-4200- 8/31/2015