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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: vvww.sjgov.orcilehd <br />PUMP INSPECTION CHECK LIST <br />Address: <br />\ab \ -9V.,op ,4--tz i>TD 1 r-v\ t--.)•• -•%f-_-,PN- <br />Permit#: <br />\,.i? 0 (t,'-k z-A-3 -1 r <br /> <br />Inspection Date: <br />(O a 124 <br />Parameter/Standard Meets SJC Standards? Comments/Measuremen S/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (extends 2' from <br />casing) Yes IA No LII NA <br />Casing extends at least 12" above grade Yesr2 No LIII NA <br />Casing extends at least 1" above pedestal Yes El No NA <br />Free of cracks/contiguous with annular seal Yes EZj NA No <br />Graded to allow drainage away from casing Yes No Lii NA <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes E14 No LII NA <br />Seal between all pipe columns and casing Yes No NA LII <br />Sounding tube/air vents sealed properly Yes 17 No NA <br />Chlorination port available and sealed properly Yes No NA <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 LII <br />Adequately installed check valve or BFP device Yes No NA <br />Cross connections (ex: chemical feeders hooked <br />to distribution system/ag flood irrigation from <br />domestic supply) Yes - No 1 NA / <br />Air gap of at least 6" (same as pipe diameter) Yes No 11111 NA I-7 <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes No LII NA LI <br />Well/Pump free from excessive vegetation Yes I7 No NA LII <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes No <br />If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes LV No <br />Photograph taken and attached to record Yes No LI <br />OTHER: <br />Comments: <br />Inspected By: Aaron Gooderh Title: Registered Environmental Health Specialist <br />Received By: 4 a Lgt.j.)\, , Date: L i 7 \) -2..c:57.A <br />••••••. <br />EH-4200- 8/31/2015