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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: 5 y , <br />/, Z-cr( ' ( - fl---7-, <br />Permit#: <br />7) ? a <br />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 Liii No Li NA Li <br />Casing extends at least 12" above grade Yes Li No NA LII <br />Casing extends at least 1" above pedestal Yes Li No Li NA Li <br />Free of cracks/contiguous with annular seal Yes Li No LI NA LII <br />Graded to allow drainage away from casing Yes No Li NA Li <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes MI 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 Li No Li NA Li <br />Chlorination port available and sealed properly Yes Li 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 No Li NA Li <br />Adequately installed check valve or BFP device Yes ET 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 <br />Air gap of at least 6" (same as pipe diameter) Yes Li No Li NA Li <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes No Li NA Li <br />Well/Pump free from excessive vegetation Yes Li No Li NA Li <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes Li No Li <br />If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes Li No n <br />Photograph taken and attached to record Yes No Li <br />OTHER: <br />Comments: <br />Inspected By: F)-2-1 , v., -' it .---:. re-<1.-,", , :1_1-t;:z Title: 117 0 <br />Received By: Date: :3 ( 91/2 .,-,-) i <br />EH-4200- 8/31/2015