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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.sjoov.orgiehd <br />PUMP INSPECTION CHECK LIST <br />Address: — -- <br />. ' C , ''t iX•Cli " 1 j /S 2 6 <br />Permit#: <br />L'-C 7 '/c/ 2 <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 -, No NA <br />Casing extends at least 12" above grade Yes Fr No NA <br />Casing extends at least 1" above pedestal Yes I7 No NA <br />Free of cracks/contiguous with annular seal Yes 1/4- No NA <br />Graded to allow drainage away from casing Yes r No NA <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes Fr No Lii NA <br />Seal between all pipe columns and casing Yes L No LII NA 7 <br />Sounding tube/air vents sealed properly Yes 7- No NA <br />Chlorination port available and sealed properly Yes I I No LIII NA <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 11.-t-- No LII NA <br />Adequately installed check valve or BFP device Yes V No NA <br />Any cross connections? (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes No LI NA lij--- <br />Air gap of at least 6" (same as pipe diameter) Yes 7 No NA JIIY <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes E,--"No NA LI <br />Well/Pump free from excessive vegetation Yes Tr No NA LII <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes P No LI <br />If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes 1—No <br />Photograph taken and attached to record Yes 5-4./ No LI <br />OTHER: <br />Comments: <br />,-- <br />Inspected By: 1-c c,, ,t , y t _:. 6. e. )7CL .-.— <br />. <br />Title: ,i '1 <br />Received By: Date: :Z/ // /e/ <br />EH-4200- 8/31/2015