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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.orgiehd <br />PUMP INSPECTION CHECK LIST <br />Address: <br />.2 C, S-1 C A) ;i,, I 0,e,t,7 .-N.41,-ca4 (iA4 e, <br />Permit#: <br />(LI° 41),) '06 ---c- <br />Inspection Date: <br />-ili 1 hvi i <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 <br />Casing extends at least 12" above grade Yes No H NA <br />Casing extends at least 1" above pedestal Yes 1-Cl No H NA <br />Free of cracks/contiguous with annular seal Yes pr No I I NA I I <br />Graded to allow drainage away from casing Yes ir No H NA LII <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes 11 No H NA LII <br />Seal between all pipe columns and casing Yes VI No H NA LI <br />Sounding tube/air vents sealed properly Yes TI. No H NA <br />Chlorination port available and sealed properly Yes -TX No H NA <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 Ti No H NA <br />Adequately installed check valve or BFP device Yes I - 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 k,' <br />Air gap of at least 6" (same as pipe diameter) Yes H No H <br />-- <br />NA v <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes vi No H NA LI <br />Well/Pump free from excessive vegetation Yes 17 No H NA <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes g No <br /> If no is selected, attach an accurate map to permit Permit drawing drawing sufficient to locate well in future Yes ir 0 <br />Photograph taken and attached to record Yes 17 No <br />OTHER: <br />Corn ments: <br />,, 4 Inspected By: f-o,.,k.f,A 5 L•0 G2C,,,t . r 4.. k ).___ Title: C /I 4 , ) <br />Received By: Date: ,7_/ i / /.7,- Z t <br />EH-4200- 8/31/2015