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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.orq/end <br />PUMP INSPECTION CHECK LIST <br />Address: <br />7 cv LA) . Fedo rot /4 ,A..t... <br />Permit#: <br />opto 37o19 <br />In s pp cli9n Date: <br />V//7 <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes No K NA LII <br />Casing extends at least 12" above grade Yes No y NA <br />Casing extends at least 1" above pedestal Yes LI No I I NA LI <br />Free of cracks/contiguous with annular seal Yes ri No 1( NA LI <br />Graded to allow drainage away from casing Yes ri _ No I)C NA LI <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes X No LI NA n <br />Seal between all pipe columns and casing Yes a No ri NA LI <br />Sounding tube/air vents sealed properly Yes LI No I I NA M <br />Chlorination port available and sealed properly YesX No LI 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 No fZjI NA <br />Adequately installed check valve or BFP device Yes IKI No NA I I <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes LI No ri NA IVI <br />Air gap of at least 6" (same as pipe diameter) Yes LI No I I NAN <br />MAINTENANCE: <br />Well/Pump visible and protected from damage YesX No LI NA III <br />Well/Pump free from excessive vegetation Yes R No LI NA I I <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes E No FI <br />Permit drawing sufficient to locate well in future Yes [K" No LI If 'no' is selected, attach an accurate map to permit <br />Photograph taken and attached to record Yes R No LI <br />OTHER: <br />Comments: <br />Inspected By: 1jh-Seen/1 Why) F -9 Title: F.- /f- firaf 'eV e <br />Received By: Date: <br />EH-4200- ion1