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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.sjoov.orgiehd <br />PUMP INSPECTION CHECK LIST <br />Address: <br />1077 b"-. di:to/ h?/ fi 0/ Permit#: <br />L'OPO 0 4/2. /0 / <br />I relc5tign Date: <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2ix4" minimum) Yes .[R No NA I <br />Casing extends at least 12" above grade Yes E. No I I NA n <br />Casing extends at least 1" above pedestal Yes — No IA NA I I <br />Free of cracks/contiguous with annular seal Yes If No n NA <br />Graded to allow drainage away from casing Yes g No n NA E <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes No NA I I <br />Seal between all pipe columns and casing Yes 4 No LI NA n <br />Sounding tube/air vents Sealed properly Yes _A No NA I I <br />Chlorination port available and sealed properly Yes I No I_ j NA r <br />SAMPLE TAP AND BACKFLOIN PREVENTION: <br />Non-threaded sample tap between well head and <br />check valve or within 3' of well head Yes , No ri NA <br />Adequately installed check valve or BFP device Yes No NA <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes Li No FT NA n <br />Air gap of at least 6" (same as pipe diameter) Yes E No NA FT <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes g No NA 11111 <br />Well/Pump free from excessive vegetation Yes No I NA I I <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes [-- No I <br />If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes H. No <br />Photograph taken and attached to record Yes H' No I I <br />OTHER: <br />Comments: <br />Inspected By: fr-_,75771-frfi-1-1041--11) Title: c.5 r- /2 :4,4' <br />Received By: Date: <br />/14 11(1.1