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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.sjgov.org/ehd <br />PUMP INSPECTION CHECK LIST <br />Address: <br />75---oZ- I Vc..( S r '1 11\ f)"1 I 1 A C e 10 ,2)<-- 3s, it, , <br />Permit#: 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 Lii NA <br />Casing extends at least 12" above grade Yes 0 No Lii NA I I <br />Casing extends at least 1" above pedestal Yes I No NA <br />Free of cracks/contiguous with annular seal Yes No LII NA <br />Graded to allow drainage away from casing Yes q No LI NA LI <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes CI No fl NA LI <br />Seal between all pipe columns and casing Yes F71 No 7 NA <br />Sounding tube/air vents sealed properly Yes Pi No NA <br />Chlorination port available and sealed properly Yes 17/ No LII NA LII <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 171 No LII NA LI <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 LI No LII NA 7 <br />Air gap of at least 6" (same as pipe diameter) Yes No LI NA v <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes Er No LI NA LI <br />Well/Pump free from excessive vegetation Yes rt7( No LII NA LI <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes pi No LII <br /> If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes Iii No I I <br />Photograph taken and attached to record Yes q I No LI <br />OTHER: <br />Comments: <br />Inspected By: (,(,',.r\c(-7 ;c' t_ct v-tA L, i\AA!..IL Title: 1":`: 14 <br />Received By: Date: '). 1 ( ()CIL 1 <br />EH-4200- 8/31/2015