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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 sigov.org/ehd <br />PUMP INSPECTION CHECK LIST <br />Address: / <br />t_ck '—k -uL, t c, c , 6.[.--- V <br />Permit#: <br />LK, iL-C C 11/(C, i—I <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 IX No El NA El <br />Casing extends at least 12" above grade Yes I i,1 No El NA LII <br />Casing extends at least 1" above pedestal Yes IZI' No LII NA LII <br />Free of cracks/contiguous with annular seal Yes 7 No LII NA ElI <br />Graded to allow drainage away from casing Yes 0 No LI NA El <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes ,y No I I NA Lii <br />Seal between all pipe columns and casing Yes Ft No El NA El <br />Sounding tube/air vents sealed properly Yes 11/17 No El NA El <br />Chlorination port available and sealed properly Yes 7 No El NA El <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 M No El NA El <br />Adequately installed check valve or BFP device Yes b. No El NA 7 <br />Any cross connections? (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes I I No El NA L. - <br />Air gap of at least 6" (same as pipe diameter) Yes I I No El NA Fr <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes F No El NA El, <br />Well/Pump free from excessive vegetation Yes Fi- No El NA El <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes I No El <br />If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes V- No El <br />Photograph taken and attached to record Yes E No El <br />OTHER: <br />Comments: <br />Inspected By: rre- i ,,t C : f (,.; ,C.17,:-,--e-, <_ )..)\<--/ 7 <br />--- <br />Title: Aq4.2: C---z^z-i -I <br />Received By: Date: 21101 C L‘ <br />EH-4200- 8/31/2015