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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 />Q 1C-DC) c 's•'''`-f-, Ce•• CC'S l.--l.K)N3 l <br />Permilt: <br />\).'R cyfo 1/41\-i--. <br />Inspection Date: <br />(> \ -z-5 \ 2.-\ <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (extends 2' from <br />casing) Yes 12( No NA LI <br />Casing extends at least 12" above grade Yes It/ No E NA LI <br />Casing extends at least 1" above pedestal Yes 7 No NA LI <br />Free of cracks/contiguous with annular seal Yes 171 No Lii NA LI <br />Graded to allow drainage away from casing Yes d No LI NA LI <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes ii No LI NA LI <br />Seal between all pipe columns and casing Yes DI No LI NA LI <br />Sounding tube/air vents sealed properly Yes No LI NA LI <br />Chlorination port available and sealed properly Yes No LI NA LI <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 LI No 1171 NA V.,(--Y-Nc......-, S %...b.Jszt ,s_.,_ "\--C\R <br />Adequately installed check valve or BFP device Yes 11 No LI NA LI <br />Cross connections (ex: chemical feeders hooked <br />to distribution system/ag flood irrigation from <br />domestic supply) Yes LI No 12( NA 0/ <br />Air gap of at least 6" (same as pipe diameter) Yes LI No LI NA D111 <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes No LI NA LI <br />Well/Pump free from excessive vegetation Yes No LI NA LI <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes No LI <br />If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes L11. No <br />Photograph taken and attached to record Yes No LI <br />OTHER: <br />Comments: <br />_ U6— C.1.- Ls, SR2L-CI -c\PR <br />N1\1 <br />'S - <br />— ....>.- <br />f\P <br />_ ,___„_„ _,,,z, tt,N•S T..- ••- • )('t C('-‘"(--‘ \--114-C' r—O r:).v.1/4-1—--C. '6--‘ ti• v-1/4. t..A.e <br />Lt • <br />41 Inspected By: Aaron Gooderham QS....WeYN :41% IS tlik‘b b I \NN Title: Registered Environmental Health Specialist <br />Received By: I•.)0 b t..) C:t_ & tJ •S r._T ..--- . Date. ---- <br />EH-4200-- 8/31/2015