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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.sjciov.orq/ehd <br />PUMP INSPECTION CHECK LIST <br />Address: 6- -- <br />2 / $17.c- ,' ArkiliAl)./ (r : ef1.4 ' ( 1)--S .7 -2 <br /> <br />/ 'i. <br />Permit#: <br />1-A2r11;6) 9(1' ‘-/7 <br />Inspection Date: <br />2 /2 jX 2v'" <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes El No 111 NA 17 <br />Casing extends at least 12" above grade Yes wr No NA 17 <br />Casing extends at least 1" above pedestal Yes Eli No Ill NA 17 <br />Free of cracks/contiguous with annular seal Yes PI No 17 NA LI <br />Graded to allow drainage away from casing Yes F71 No NA 17 <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes No 17 NA 17 <br />Seal between all pipe columns and casing Yes I, , No 17 NA 17 <br />Sounding tube/air vents sealed properly Yes 17] No 17 NA 17 <br />Chlorination port available and sealed properly Yes EI No IIl NA 17 <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 El No liii <br />I <br />NAL:, i <br />Adequately installed check valve or BFP device Yes yr No I 1 NA lti-2, <br />Any cross connections? (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes No LI NA Fr <br />Air gap of at least 6" (same as pipe diameter) Yes U No 17 NA T ' <br />MAINTENANCE: <br />Well/Pump visible and protected from damage <br />, - <br />Yes IV1 No 17 NA 17 <br />Well/Pump free from excessive vegetation Yes FT No 17 NA 17 <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes LI No LII <br />If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes I' No 17 <br />Photograph taken and attached to record Yes No 17 <br />OTHER: <br />Comments: <br />Inspected By: -t.c_, ( r 69-a---4,. , A,,i-. Title: ril/ .4.-:;,5 i ,.., I <br />Received By: Date: 2-/ .7 v <br />EH-4200- 8/31/2015