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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East HazeIton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: vvww.sigov.orgiehd PUMP INSPECTION CHECK LIST Address: t KTh i") f Permit#: kg' LI Z Og.6 Inspection Date: hi 6(eArE4 Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (extends 2' from casing) Yes LI No LII NA V ,c-rz,. T-1.---.1 ii, v;) ....3-K-p.4.,_. v----v Casing extends at least 12" above grade Yes V No NA LII Casing extends at least 1" above pedestal Yes 0 No NA Free of cracks/contiguous with annular seal Yes 17 No NA LI Graded to allow drainage away from casing Yes 0 No NA LI SANITARY SEAL: Well is sealed between pump and casing Yes d No NA LI Seal between all pipe columns and casing Yes No LI NA LI Sounding tube/air vents sealed properly Yes Ei7J No LI NA LI Chlorination port available and sealed properly Yes li No NA Lii SAMPLE TAP AND BACKFLOW PREVENTION Non-threaded sample tap between well head and check valve or within 3' of well head Yes No NA LI Adequately installed check valve or BFP device Yes No LI NA LI Cross connections (ex: chemical feeders hooked to distribution systern/ag flood irrigation from domestic supply) Yes No rli NA p Air gap of at least 6" (same as pipe diameter) Yes LIII No LI NA DI I MAINTENANCE: Well/Pump visible and protected from damage Yes No NA LI Well/Pump free from excessive vegetation Yes i No LI NA LI MISCELLANEOUS: Permit drawing represents actual location of well Yes No LI If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes No LI Photograph taken and attached to record Yes • No n OTHER: Comments: \So "C,`-5 ci••.-.6 ‘-j / R 1/4.).1,•4? ‘,... 0 Inspected By: Aaron Gooderham (51-Z719Y-N- : Title: Registered Environmental Health Specialist Received By :7,---4601.4.y. ,:?:c::::::;91 Date: EH-4200- 8/31/2015