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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.orq/ehd <br />PUMP INSPECTION CHECK LIST <br />Address:Permit#: <br />u 2 &'' 1c tr- t ' t'd/ Fc(f), to-, C# (1 c(5.2 0 ( vroe,-)-//bb - <br />Inspection Date: <br />2 /2 1/2 ,u <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes a No ri NA LII <br />Casing extends at least 12" above grade Yes Fr No 7 NA LII <br />Casing extends at least 1" above pedestal Yes F7` No n NA LII <br />Free of cracks/contiguous with annular seal Yes 171T No H NA <br />Graded to allow drainage away from casing Yes 0 No H NA <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes [Ti" No H NA <br />Seal between all pipe columns and casing Yes No H NA LII <br />Sounding tube/air vents sealed properly Yes 7/ No LII NA <br />Chlorination port available and sealed properly Yes I --7 -' No H 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 17- No H NA <br />Adequately installed check valve or BFP device Yesir:1- No H 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 V <br />Air gap of at least 6" (same as pipe diameter) Yes LI No H NA El <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes i/r: No H NA <br />Well/Pump free from excessive vegetation —/ Yes 1, No H NA <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes111; No <br />If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes Fr No H <br />Yes 174 / N o Photograph taken and attached to record <br />OTHER: <br />Comments: <br />Inspected By: u•t\ CI r,L U2-CLCCI f, 0'4'0 'L Title: t- ii k ' [ i, j;c1, \ t <br />Received By: Date: 7 i i_ 4 ['fl'), I <br />EH-4200- 8/31/2015