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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: wwvv.sigov orgiehd <br />PUMP INSPECTION CHECK LIST <br />Address: <br />1 Lc '--)Ct.C((-1"0\C <br />p <br />P,d i C1-/ / 16 't 4, 'iN Lit- qf 2 ) <br />Permit#: <br />LA),Pcz-) ttli;;,g <br />Inspection Date: <br />2/2 tt/2 • - <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes V No NA <br />Casing extends at least 12" above grade Yes / No LII NA liii <br />Casing extends at least 1" above pedestal Yes 1/- No LII NA <br />Free of cracks/contiguous with annular seal Yes 7' No NA <br />Graded to allow drainage away from casing Yes FT No NA <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes Illi No NA <br />Seal between all pipe columns and casing Yes E No NA LI <br />Sounding tube/air vents sealed properly Yes 21 No NA LII <br />Chlorination port available and sealed properly Yes No <br />- <br />NA Ft <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 Fr <br />Adequately installed check valve or BFP device Yes No NA <br />Any cross connections? (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes Ea' No NA LII <br />Air gap of at least 6" (same as pipe diameter) Yes LII No NA <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes No LI NA LI <br />Well/Pump free from excessive vegetation Yes I1 No 1111 NA I I <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes n No LII <br />If no is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes IT No n <br />Photograph taken and attached to record Yes /No LI <br />OTHER: <br />Cornments: <br />Inspected By: )(1: Laert- t- itk, I <br />, • <br />Title: LI 45 SIS-/,1. "i- <br />Received By: Date: It '2 LI 12N-1 <br />EH-4200- 8/31/2015