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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 />(<,- 94"-<V<C< W, Cci's3C,1>‘-5'D <br />Permit#: <br />\I,AF)0`3\\.%1->\ <br />Ins ectIon Date: <br />Parameter/Standard Meets SJC Standards? Comments/Measureme ts/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (extends 2' from <br />casing) Yes No El NA El <br />Casing extends at least 12" above grade Yes'14 No El NA LI <br />Casing extends at least 1" above pedestal Yes No El NA El <br />Free of cracks/contiguous with annular seal Yes No ISIN NA El <br />Graded to allow drainage away from casing Yes)SIN <br />I <br />D El NA El <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes' iSk No NA El <br />Seal between all pipe columns and casing Yes 4 No El NA El <br />Sounding tube/air vents sealed properly Yes R No El NA El <br />Chlorination port available and sealed properly Yes IN\No El NA El <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 NA El <br />Adequately installed check valve or BFP device Yes No El NA El <br />Cross connections (ex: chemical feeders hooked <br />to distribution system/ag flood irrigation from <br />domestic supply) Yes El NoINL NA El <br />Air gap of at least 6" (same as pipe diameter) Yes El No El NArN <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yest\ No El NA El <br />Well/Pump free from excessive vegetation YesNE\ No El NA El <br />MISCELLANEOUS: , <br />Permit drawing represents actual location of well YeilD No El <br />If no is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes 1,No El <br />Yes 1SL,No El Photograph taken and attached to record <br />OTHER: <br />Comments: <br />(sio\l,&Q • <br />Inspected By: Aaron Gooderham QLS&Lsicv. A..L-6 444: Title: Registered Environmental Health Specialist <br />Received By: NI ko 0 .., ,..r....v- c•-__ 9 (cALA.c),-)Aoc-,•-- Ii.v-kyrroS c-Poct-u. Date: <br />EH-4200- 8/31/2015