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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.org/ehd <br />PUMP INSPECTION CHECK LIST <br />Address: /;) , <br />( C.-I? /1/1 ,- iciLs - iLi .--1-1f,61:7J , 6--42 k-2/c- 1 <br />Permit#: <br />(.2,1,9 () <br />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 171 No L1 NA Li <br />Casing extends at least 12" above grade 7 Yes IL) No LII NA LII <br />Casing extends at least 1" above pedestal Yes Iv I No Li NA LII <br />Free of cracks/contiguous with annular seal Yes 71 No Lii NA Li <br />Graded to allow drainage away from casing Yes 1771 No LII NA LII <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes Er No Li NA Li <br />Seal between all pipe columns and casing Yes F,-1 No LII NA LI <br />Sounding tube/air vents sealed properly Yes [71 No Li NA n <br />Chlorination port available and sealed properly Yes I I No Li NA Li <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 V No Li NA Li <br />Adequately installed check valve or BFP device Yes V No LI NA LII <br />Any cross connections? (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) _ Yes LII No Li NA ri ,-- <br />Air gap of at least 6" (same as pipe diameter) Yes No NA riT <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes or No Li NA Li <br />Well/Pump free from excessive vegetation Yes v No Li NA Li <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes Ft. No Li <br />If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes Ff No LI <br />Photograph taken and attached to record Yes No LI <br />OTHER: <br />Cornments: <br />Inspected By: ' I \ `i L •6 Lc u' i. ' \i",-AH Title: Il A-c,C-il A 1 <br />Received By: Date: '),_( I. Li iq a 1 <br />EH-4200- 8/31/2015