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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.orq/ehd <br />PUMP INSPECTION CHECK LIST <br />Address: <br />.c3 i,•, , r.-, <br />1 <br />tu, n i'vir,c11 Ile'It 4-ttlii-y.,r) <br />Permit#: Inspection Date: <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes Ni No NA <br />Casing extends at least 12" above grade Yes ITT- No LII NA LII <br />Casing extends at least 1" above pedestal Yes 7t No LII NA LI <br />Free of cracks/contiguous with annular seal Yes Ft " 6 No NA LI <br />Graded to allow drainage away from casing Yes Ft No LII NA LII <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes ITT No NA Eli <br />Seal between all pipe columns and casing Yes No LII NA LII <br />Sounding tube/air vents sealed properly Yes 1-1 No NA LII <br />Chlorination port available and sealed properly Yes No NA Eli <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 II No NA LI <br />Adequately installed check valve or BFP device Yes r No 7 NA LI <br />Any cross connections? (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes C. No r1 NA - <br />Air gap of at least 6" (same as pipe diameter) Yes Fl No — NA PT <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes FT No LII NA LI <br />Well/Pump free from excessive vegetation Yes [i I No LII NA Lii <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes ErNo LI <br />If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes Fr No LI <br />Photograph taken and attached to record Yes [7 No LI <br />OTHER: <br />Cornments: <br />Inspected By: r) ' )• eve, L . ii:vt-i ,L, tk.....4 , 1._ Title: 6' 14 4 , <br />Received By: <br />i c <br />Date: 2( 2 z1/2 ,-),1 <br />EH-4200- 8/31/2015