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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.sjqov.orq/ehd <br />PUMP INSPECTION CHECK LIST <br />Address: <br />SIC' 't jiic,,,„.f,,, ikii vr-b, , <br />Permit#: Inspection Date: <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes H-- No LI NA El <br />Casing extends at least 12" above grade Yes Fl No El NA El <br />Casing extends at least 1" above pedestal Yes I kr No El NA El <br />Free of cracks/contiguous with annular seal Yes vl No I 1 NA n <br />Graded to allow drainage away from casing Yes I-1/ No El NA El <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes F1, No El NA El <br />Seal between all pipe columns and casing Yes 177 No El NA El <br />Sounding tube/air vents sealed properly Yes IVI No El NA El <br />Chlorination port available and sealed properly Yes 71 No El NA n <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 Fr No El NA El <br />Adequately installed check valve or BFP device Yes I j No El NA El <br />Any cross connections? (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes El No El NA a <br />Air gap of at least 6" (same as pipe diameter) Yes El No I I NA -a <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes a No pi NA El <br />Well/Pump free from excessive vegetation Yes 7 No El NA El <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes IT,T No El <br />If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes 71 No El <br />Photograph taken and attached to record Yes -9 No El <br />OTHER: <br />Comments: <br />,--- Inspected By: 1,-1,-t ,zi , S ( C (/ , , ii-e,-,1 Title: Title: 07 11 <br />Received By: Date: 1( /1- (2- I <br />EH-4200- 8/31/2015