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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 />2 / 3' - $e 1,„ / <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 Fr No Li NA 1 I <br />Casing extends at least 12" above grade No NA I I Yes Ivi <br />Casing extends at least 1" above pedestal Yes 7 No H NA <br />Free of cracks/contiguous with annular seal Yes F No H NA <br />Graded to allow drainage away from casing Yes la No LII NA <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes liz No I I NA LI <br />Seal between all pipe columns and casing Yes IT No H NA rl <br />Sounding tube/air vents sealed properly Yes ly" No 7 NA <br />Chlorination port available and sealed properly Yes 17 No 7 NA ri <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 In No H NA <br />Adequately installed check valve or BFP device Yes Ty No I I NA <br />Any cross connections? (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes H No H NA <br />Air gap of at least 6" (same as pipe diameter) Yes H No H NA Eli <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes ul, No H NA <br />Well/Pump free from excessive vegetation Yes 0 No H NA I I <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes 1-1- No <br />If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes rt No H <br />Yes 11(No Photograph taken and attached to record <br />OTHER: <br />Comments: <br />Inspected By: ilr.,...,-, 4..)c,:,-, (---(2.e.--z_ ; e.- 4,,,_ Title: r (1 , , _ --1 <br />Received By: Date: 2---/i/ /2-g% 2- I <br />EH-4200- 8/31/2015