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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.org/ehd <br />PUMP INSPECTION CHECK LIST <br />Address: <br />,A-/ (.6 e ( ‘, kc c .h.el , / <br />Perrnit#: <br />/ft) 0 et/ ‘, 6) 7 <br />Inspection Date: <br />Zi/1/2 1'2/ <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes i, No NA Lii <br />Casing extends at least 12" above grade Yes 1-- No Lii NA <br />Casing extends at least 1" above pedestal Yes FA' No NA <br />Free of cracks/contiguous with annular seal Yes1171 No NA I I <br />Graded to allow drainage away from casing Yes E7 No NA <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes 1:k No NA <br />Seal between all pipe columns and casing Yes E' No NA liii <br />Sounding tube/air vents sealed properly Yes Fr No Lii NA <br />Chlorination port available and sealed properly Yes E. No 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 /- No NA <br />Adequately installed check valve or BFP device Yes 171,7 No LII NA <br />Any cross connections? (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes No NAil-.2' <br />Air gap of at least 6" (same as pipe diameter) Yes No LIII NA III - <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes 17 No NA <br />Well/Pump free from excessive vegetation Yes EV No NA LII <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes ',''No <br />If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes Fr No <br />Photograph taken and attached to record Yes <br />/ <br />I( No <br />OTHER: <br />Comments: <br />Inspected By: fri;,i_ b. z- (,, 6,----,__z4 ,,,' ,/, z_ Title: 67 ,4/ <br />Received By: Date: 7/4 /2--4 <br />EH-4200- 8/31/2015