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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.orq/ehd <br />PUMP INSPECTION CHECK LIST <br />Address: <br />'2 c. 3 Lk; , li i 6/-1( -,g-1 45 t idd 4A -2 id ."--2 14, , <br />Permit#: Inspection Date: <br />Parameter/Standard i <br />Meets SJC Standards? Comments/Measurements/ Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes [- No NA <br />Casing extends at least 12" above grade Yes ri2- No LII NA <br />Casing extends at least 1" above pedestal Yes V No IIJ NA <br />Free of cracks/contiguous with annular seal Yes 1-R- No E NA I I <br />Graded to allow drainage away from casing Yes r• No NA <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes Lii No NA <br />Seal between all pipe columns and casing Yes LIII No NA LII <br />Sounding tube/air vents sealed properly Yes ri No E NA LII <br />Chlorination port available and sealed properly Yes No LII NA LII <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 NA [— <br />Adequately installed check valve or BFP device Yes EV No NA <br />Any cross connections? (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes LIII No NA LII <br />Air gap of at least 6" (same as pipe diameter) Yes I I No LII NA H <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes No NA <br />Well/Pump free from excessive vegetation Yes No NA <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes LI No E <br />If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes LIII No <br />Photograph taken and attached to record Yes LI No LI <br />OTHER: <br />Comments: " -1 / 1-0 L.. i„) c; • ( ' at y /e 1 / ce <br />,- <br />Inspected By: ct-c , rt) (CFA/7; /i, 412., Title: ,67 i•-*/ <br />Received By: Date: // if -19_09 v <br />EH-4200- 8/31/2015