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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East HazeIton Avenue, Stockton, CA 95205-6232 <br />refephone: (209) 468-3420 Fax: (209) 468-3433 Web: wvvw.sigov.org/ehd <br />PUMP INSPECVON CHECK LIST • _ <br />Address: <br />kil \0 t oRAti-A--0V'oksi'-cm -,i) • ..11 , c-< c\5 2-% <br />Permit#:spection <br />'*)$I t oloct o'l 6 Ibiltiz <br />Date: <br />ail 4 <br />Parameter/Standard Meets SJC Standards? Comments/Measurements! Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x21x4" minimum) Yes kJ No NA I I <br />Casing extends at least 12" above grade Yes 1-7 No I I NAa <br />Casing extends at least 1" above pedestal Yes No Li NA ID <br />Free of cracks/contiguous with annular seal Yes No 11 NA <br />Graded to allow drainage away from casing Yes \,..11 No LI NA <br />SANITARY .SEAL: <br />Well is sealed ;..- T, - - a .. -: -, Yes id No NA) I <br />Seal between all pipe columns and casing Yes No I NA I I <br />Sounding tube/air vents Sealed properly - Yes I I No I NA 0 <br />Chlorination port available and sealed properly Yes No I NA 'I <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 No) I NA Ish <br />Adequately installed check valve or BFP device Yes — No! I NA <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes) No I \INA ' <br />Air gap of at least 6" (same as pipe diameter) Yes I No --q- NA I I <br />MAINTENANCE: . <br />Well/Pump visible and protected from damage Yes NO NA I I <br />Well/Pump free from excessive vegetation Yes J No! I NA <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes N. No Li . <br />If no is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes q No <br />Photograph taken and attached to record Ye S IS) No _J <br />OTHER: <br />Comments: <br />, <br />ik=k 0CZ U-\ <br />- <br />, <br />\\&\ \ <br />Inspected Inspected By: NI i. ')Ii Title: Vk VS4J $ <br />Received By: Date: <br />fl/n.1 Mr14C