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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: <br />if— 4--tvih.., 1,A, pr ts) 't- .-c._..0 i <br />Permitit: <br />Lk % <br />Inspection Date: <br />\ S <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (extends 2' from <br />casing) Yes No LII NA El <br />Casing extends at least 12" above grade Yes No El NA El <br />Casing extends at least 1" above pedestal Yes IZI No El NA El <br />Free of cracks/contiguous with annular seal Yes Z No El NA LI <br />Graded to allow drainage away from casing Yes Lii No El NA.P --- c.,pcs;) ,r 1...,, ?,Ac,„v <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes No El NA LI <br />Seal between all pipe columns and casing Yes No El NA El <br />Sounding tube/air vents sealed properly Yes No El NA El <br />Chlorination port available and sealed properly Yes No El 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 4 No El NA El <br />Adequately installed check valve or BFP device Yes 0 No El NA El <br />Cross connections (ex: chemical feeders hooked <br />to distribution system/ag flood irrigation from <br />domestic supply) Yes El No ff NA <br />Air gap of at least 6" (same as pipe diameter) Yes El No El NA <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes 71 No El NA El <br />Well/Pump free from excessive vegetation Yesg No El NA El <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes 0 No El <br />If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes lj No El <br />Yes V± No El Photograph taken and attached to record <br />OTHER: <br />Comments: <br />- \\\1? 1) \1't<,." "\O NA, 'VP(\s—k- -s--c- \.< <br />St)°\ NIN) VAJ, C) i•iC-1/4-)Nir <br />Inspected By: Aaron Gooderham c---...ejanf CaSCZ. et11). Title: Registered Environmental Health Specialist <br />Received By: Date: <br />EH-4200- 8/31/2015