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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.sjqov.orgiehd <br />PUMP INSPECTION CHECK LIST <br />Address: 2 Is,....1 L i ,diti (well <br />r"-- i <br />Permiti:4490 0 ,iio 3q InviViDatze:) <br />Parameter/Sadard Meets SJC Standards? Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yesy No I I NA liii <br />Casing extends at least 12" above grade Yes ry No I I NA H <br />Casing extends at least 1" above pedestal Yes ly No NA <br />Free of cracks/contiguous with annular seal Yes VI No NA H <br />Graded to allow drainage away from casing Yes rl. I No NA <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes 1'%. No NA I 1 <br />Seal between all pipe columns and casing Yes,- No Liii NA <br />Sounding tube/air vents sealed properly Yes Z No NA I I <br />Chlorination port available and sealed properly Yes No NA <br />SAMPLE TAP AND BACKFLOIN PREVENTION. <br />Non-threaded sample tap between well head and <br />check valve or within 3' of well head Yes 1111 No NA ry <br />Adequately installed check valve or BFP device Yesl/T No LIII NA <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes No H NA 'IT <br />Air gap of at least 6" (same as pipe diameter) Yes No H NA ly. <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes1 No NA <br />Well/Pump free from excessive vegetation Yes Nt No NA <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well YeS17c-. No <br />If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes No I I <br />Photograph taken and attached to record Yes No H <br />OTHER: <br />Comments: r- <br />5-. <br />r' <br />Inspected B : Otri 0--- /43—, CIYIJK.--- Title: i2-ei3 /4 <br />Received By: Date: 7"1 -44W Z-A <br />EH-4200- 8/31/2015