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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/ehd <br />PUMP INSPECTION CHECK LIST <br />Address: <br />CA St1304h)n, CPt <br />Permit#: <br />V\A)60 ?-)C1 14 e Inspection Date: <br />eiac,/ici <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 Li NA Li <br />Casing extends at least 12" above grade Yes Ey No LI NA Li <br />Casing extends at least 1" above pedestal Yes Ld No Li NA Li <br />Free of cracks/contiguous with annular seal Yes 1 No Li NA LI <br />Graded to allow drainage away from casing Yes Er No Li NA Li <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes Ea/ No Li NA Li <br />Seal between all pipe columns and casing Yes Li " No Li NA Li <br />Sounding tube/air vents sealed properly Yes 27 No Li NA LI <br />Chlorination port available and sealed properly Yes Ld. No Li NA LI <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 p/ No Li NA Li <br />Adequately installed check valve or BFP device Yes ..--No Li NA LI <br />Any cross connections? (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes LI No LI NA Fr <br />Air gap of at least 6" (same as pipe diameter) Yes Li No LI NA Hz <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes 1-7 No Li NA LI <br />Well/Pump free from excessive vegetation Yes /1 No Li NA Li <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes ivr No Li <br />If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes ErNo Li <br />Photograph taken and attached to record Yes ErNo LI <br />OTHER: <br />Comments: <br />Inspected By: /i) 'Kt:SA-1"n° -.Snc-1-1-ev-- r\ Title: E-}‘ A---i:L.-;?,‘"3-17-1 n 1-- <br />Received By: Date: <br />EH-4200- 8/31/2015