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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East HazeIton Avenue, Stockton, CA 95205-6232 <br />Tefephone: (209) 468-3420 Fax.: (209) 468-3433 Web: www.sigov.orq/ehd <br />PUMP INSPECTION CHECK LIST • <br />Address: <br />S. tIcC- CINZ ik, i gol•). U1 /4. ekS-53-7 c <br />Permit#: <br />Wc) b 0 Sct lb <br />Inspection Date: <br />lic/17)1DIq <br />Parameter/Standard Meets SJC Standards? comments/Measuremerits/ Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x27x4" minimum) Yes No Li NA 1 1 <br />Casing extends at least 12" above grade Yes v No NA n _ <br />Casing extends at least 1" above pedestal Yes 1J No n NA <br />Free of cracks/contiguous with annular seal Yes E No kl NA li <br />Graded to allow drainage away from casing Yes I-1 No kll NA LI t9 0" \11.- 'N'. tNk13-4\,J <br />SANITARY SEAL: <br />Well is is sealed between pump and casing Yes 1_,.,„ No NA n <br />Seal between all pipe columns and casing Yes FJ No Lii NA <br />Sounding tube/air vents Sealed properly - Yes IJ No n NA <br />Chlorination port available and sealed properly Yes No LI NA rl <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 FI No rd NA r1 c\) 4"'' b WR \S•4--- \-ky12 <br />Adequately installed check valve or BFP device Yes -0 No n NA Li <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) <br />. <br />Yes Li No J NA n <br />Air gap of at least 6" (same as pipe diameter) Yes jill— No n NA 1\11 <br />MAINTENANCE: . . <br />Well/Pump visible and protected from damage Yes I No fl NA 17 .1 - <br />Well/Pump free from excessive vegetation _ _ Yes fq No n NA LI 1 <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes No <br />If no is selected, attach an accurate map to permit 'Permit drawing sufficient to locate well in future Yes ki No C <br />Photograph taken and attached to record Yes No LI <br />OTHER: . <br />Comments: <br />• <br />• <br />) <br />- 1 <br />• <br />Inspected By: \ <br />. <br />, VN \ ', <br />i <br />Title: 'V& W-f".§ , <br />Received By: Date: <br />nin.1 P1/14 C