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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: I <br />ic-)(aici L E'e9ht Mae kcl. V>1n6en, CO qc59--3) <br />Permit#: <br />'VVRA-l-i-G4 -2`f- <br />Inspection Date: <br />121-,4, ii C1 <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes 2' No El NA El <br />Casing extends at least 12" above grade Yes I / No NA El <br />Casing extends at least 1" above pedestal Yes Ff No NA El <br />Free of cracks/contiguous with annular seal Yes Er No El NA El <br />Graded to allow drainage away from casing Yes 2/ No El NA LI <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes 17 No El NA El <br />Seal be:ween all pipe columns and casing Yes 7/ No ri NA El <br />Sounding tube/air vents sealed properly Yes 27 No El NA El <br />Chlorination port available and sealed properly Yes No LI NA El <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 El No 1 I E' ,NA <br />Adequately installed check valve or BFP device Yes El No k71 NA LI t<ic-> Oneck va\ve <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes El <br />/ <br />No I l' NA El <br />Air gap of at least 6" (same as pipe diameter) Yes El No [7 NA FT" <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes I/ No NA El <br />Well/Pump free from excessive vegetation Yes +77 No El NA El <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes [V No LI <br />If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes 7/ No El <br />Photograph taken and attached to record Yes VNo El <br />OTHER: <br />Comments: <br />, <br />Inspected By: ,-&-cche--,i ve-t-e r C\ Title: E <br />Received By: By: Date: <br />EH-4200- 8/31/2015