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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 siqov.orq/ehd <br />PUMP INSPECTION CHECK LIST <br />Address:-Permit#: , - ( , - <br />—I 0 t't I kr,),(Aey i;Zell -4C..1,,ip 4' tt.4- Iii,' <br />, <br />I tif 0 //3 <br />Inspection Date: <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes 1-4- No NA LI <br />Casing extends at least 12" above grade Yes ,4 No Lii NA LI <br />Casing extends at least 1" above pedestal Yesir,r No El NA LI <br />Free of cracks/contiguous with annular seal Yes FO/ No LII NA H <br />Graded to allow drainage away from casing Yes 1-/ No El NA El <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes Kr No El NA El <br />Seal between all pipe columns and casing Yes F.I. No LII NA LII <br />Sounding tube/air vents sealed properly Yes / No El NA El <br />Chlorination port available and sealed properly Yes El No F ..-- <br />NA R <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 LI NA P' <br />Adequately installed check valve or BFP device Yes V No NA El <br />Any cross connections? (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes 1-/ No El NA LI <br />Air gap of at least 6" (same as pipe diameter) Yes El No El NA <br />MAINTENANCE: <br />Well/Pump Well/Pump visible and protected from damage Yes No El NA El <br />Well/Pump free from excessive vegetation Yes V No El NA El <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes El- No El <br />If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes RI' No El <br />Photograph taken and attached to record Yes a No El <br />OTHER: <br />Cornments: <br />Inspected By: --i-,.. c‘ i ; °, c z , 1, 2 , y Title: H ; ,- <br />Received By: Date: 2 I I --7 12 ,r) / <br />EH-4200- 8/31/2015