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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.orgiehd <br />PUMP INSPECTION CHECK LIST <br />Address: <br />\114-)Q\K, ,I.\1.`'c'(N,- QC:. l'Nr4. 'C ''6‘,A-CSi'', 1 <br />Permitt: <br />\)•-V uk \ k)L' \ <br />Inspection <br />i <br />Date: <br />)7.—L <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (extends 2' from <br />casing) Yes\N No El NA El <br />Casing extends at least 12" above grade YesN No El NA Eli <br />Casing extends at least 1" above pedestal Yes" N No El NA El <br />Free of cracks/contiguous with annular seal Yes1N. No El NA El <br />Graded to allow drainage away from casing YestL No El NA El <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes' q No El NA El <br />Seal between all pipe columns and casing Yes'R No El NA El <br />Sounding tube/air vents sealed properly Yes` l No NA El <br />Chlorination port available and sealed properly Yes 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" ISI No El NA El <br />Adequately installed check valve or BFP device Yes' q No El NA El <br />Cross connections (ex: chemical feeders hooked <br />to distribution system/ag flood irrigation from <br />domestic supply) Yes El Notl,. NA El <br />Air gap of at least 6" (same as pipe diameter) Yes El No El NAN\ <br />MAINTENANCE: <br />Well/Pump visible and protected from damage <br />1 <br />Yesn\ No El NA El <br />Well/Pump free from excessive vegetation Yes1SK No El NA El <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes't No El <br />If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes No <br />Photograph taken and attached to record Yes No El <br />OTHER: <br />Comments: <br />cco ..)...N.Dc:. • . <br />k , <br />Inspected By: Aar n Gooderham gib 4:441 if <br />A <br />Title: Registered Environmental Health Specialist A <br />Received By: AAA ACA Of r _ Date: <br /> <br />EH-4200- 8/31/2015