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SAN aIOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.slgov.orq/ehd <br />PUMP INSPECTION CHECK LIST <br />EH -4200- 8/31 /2015 <br />Address: <br />� � c Z �� l r�"� �� �,. � <br />E: C� � <br />� <br />Permit#: <br />U.'Po�,� � , .. 7 <br />Inspection Date: <br />ll� e� ��� <br />Parameter/Standard <br />Meets SJC <br />Standards? <br />Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) <br />Yes <br />[l� <br />No <br />❑ <br />NA <br />❑ <br />Casin extends at least 12" above rade <br />Yes <br />�" <br />No <br />❑ <br />NA <br />❑ <br />Casing extends at least 1" above pedestal <br />Yes <br />� <br />No <br />❑ <br />NA <br />❑ <br />Free of cracks/conti uous with annular seal <br />Yes <br />� <br />No <br />❑ <br />NA <br />❑ <br />Graded to allow drainage awa from casin <br />Yes <br />®' <br />No <br />❑ <br />NA <br />❑ <br />SANITARY SEAL: <br />Well is sealed between pump and casin <br />Yes <br />['� <br />No <br />❑ <br />NA <br />❑ <br />Seal between all pipe columns and casin <br />Yes <br />� <br />No <br />❑ <br />NA <br />❑ <br />Sounding tube/air vents sealed properly <br />Yes <br />[� <br />No <br />❑ <br />NA <br />❑ <br />Chlorination port available and sealed proper) <br />Yes <br />❑`' <br />No <br />❑ <br />NA <br />❑ <br />SAMPLE TAP AND BACKFLOW PREVENTION: <br />Non -threaded sample tap between well head and <br />check valve or within 3' of well head <br />Yes <br />[� <br />No <br />❑ <br />NA <br />❑ <br />Adequately installed check valve or BFP device <br />Yes <br />[� <br />No <br />❑ <br />NA <br />❑ <br />Any cross connections? (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic sup I <br />Yes <br />❑ <br />No <br />❑ <br />NA <br />[►]�' <br />Air gap of at least 6" (same as pipe diameter) <br />Yes <br />❑ <br />No <br />❑ <br />NA <br />MAINTENANCE: <br />Well/Pump visible and protected from dams e <br />Yes <br />[✓]' <br />No <br />❑ <br />NA ❑ <br />Well/Pump free from excessive vegetation <br />Yes <br />Q" <br />No <br />❑ <br />NA <br />❑ <br />MISCELLANEOUS: <br />Permit drawin represents actual location of well <br />Yes <br />[�" <br />No <br />❑ <br />If'no' is selected, attach an accurate map to permit <br />Permit drawing sufficient to locate well in future <br />Y2S <br />� <br />NO <br />❑ <br />Photo raph taken and attached to record <br />Yes <br />No <br />❑ <br />OTHER: <br />Comments: <br />Inspected By: ,�'j; ��' � ���-�'��� <br />' <br />Title: � c�,' <br />Received By: <br />Date: �� •y <br />EH -4200- 8/31 /2015 <br />