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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.sjcov.org/ehd <br />PUMP INSPECTION CHECK LIST <br />Address: Permit#: Inspection Date: <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (extends 2' from <br />casing) YeslYI No El NA El <br />Casing extends at least 12" above grade Yes'1,, No El NA El <br />Casing extends at least 1" above pedestal Yes' No LI NA El <br />Free of cracks/contiguous with annular seal Yes N\ No El NA El <br />Graded to allow drainage away from casing Yes' q No LI NA El <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes R No El NA El <br />Seal between all pipe columns and casing Yes a No El NA El <br />Sounding tube/air vents sealed properly Yes N No El NA El <br />Chlorination port available and sealed properly Yes a No Lii 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 IN. No LII NA LI <br />Adequately installed check valve or BFP device Yes1R_ No El NA <br />Cross connections (ex: chemical feeders hooked <br />to distribution system/ag flood irrigation from <br />domestic supply) Yes El NolSt NA El <br />Air gap of at least 6" (same as pipe diameter) Yes El No El NA \ <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes1S1, No El NA El <br />Well/Pump free from excessive vegetation Yes1S1 No El NA El <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes'. No El <br />If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes '1R No El <br />Photograph taken and attached to record Yes 'No El <br />OTHER: <br />Comments: <br />v io -SS,---j--.Ny..b RO\NMS) <br />Inspected By: Aaron oode am \c•-) Title: Registered Environmental Health Specialist <br />Received By: /".- ,,e...,----- Date: <br />EH-4200- 8/31/2015