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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.sjciov.orgiehd <br />PUMP INSPECTION CHECK LIST <br />Address: , _ <br />7 C T t' t k t 4 1 Zt\po.-\c/4 (.?c-& 6,6 <br />Permit#: <br />Liofc, 1(12- liq <br />Inspection Date: <br />17—) 191 2-'n& <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes 7 No LI NA LI <br />Casing extends at least 12" above grade Yes V No LIII NA LI <br />Casing extends at least 1" above pedestal Yes W No NA LI <br />Free of cracks/contiguous with annular seal Yes 7 No n NA liii <br />Graded to allow drainage away from casing Yes F-4 No NA LI <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes FIX No LI NA LI <br />Seal between all pipe columns and casing Yes g No LI NA LI <br />Sounding tube/air vents sealed properly Yes IA No LI NA LI <br />Chlorination port available and sealed properly Yes F7 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 LI No FVNA n <br />Adequately installed check valve or BFP device Yes RI No NA <br />Any cross connections? (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes LI No LI NA Mr <br />Air gap of at least 6" (same as pipe diameter) Yes LI No LI NA R' <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes Fr No LI NA LI <br />Well/Pump free from excessive vegetation Yes R/ No LI NA n <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes R( No LI <br />If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes r— No LI <br />Photograph taken and attached to record Yes R/ No LI <br />OTHER: <br />Comments: <br />my, -phi' 1-5 ScLv-v,.-Ii_ \-1X-s9 <br />Inspected By: akir\vvt.,‘.S., ,Q(.1r-leC 4 Title: •-•:, 4 4G,,‘, <br />Received By: By: Date: Vil LI IN_ 7 0 <br />EH-4200- 8/31/2015