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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.sigov orq/ehd <br />PUMP INSPECTION CHECK LIST <br />Address :,Z 461 1 Er,- tl' <br />1-luvii 26 , ;iii-cle/1/ onrel) 5 I <br />, Permit#: <br />W V <br />n <br />009 0 3(ol In7c47 Date: c 1 -7-7,) <br />I <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes No 7 NA 7 <br />Casing extends at least 12" above grade Yes' No NA 7 <br />Casing extends at least 1" above pedestal Yes s i No NA <br />Free of cracks/contiguous with annular seal Yes* No LII NA <br />Graded to allow drainage away from casing Ye N:1 No NA Lii <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes li No NA LI <br />Seal between all pipe columns and casing Yes IN/I No NA LI <br />Sounding tube/air vents sealed properly YestA No LI NA LII <br />Chlorination port available and sealed properly Yes PI No Lii NA I I <br />SAMPLE TAP AND BACKFLOW PREVENTION. I Non-threaded sample tap between well head and <br />check valve or within 3' of well head Yes No NAM <br />Adequately installed check valve or BFP device Yesl•A No NA LI <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes LI No 7 NA' <br />Air gap of at least 6" (same as pipe diameter) Yes No 7 NA 17( <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes-14 No NA LI <br />Well/Pump free from excessive vegetation Yes 154 No NA I I <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes M No LI <br />If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes KI No <br />Photograph taken and attached to record Yes it No LI <br />OTHER: <br />Comments: n <br />Inspected By:,. <br />I (X- Ar-P VI- 14'4\ °'-- Title: iz -61-1-5 <br />Received By: Date: 5/1 .W47 <br />EH-4200- 8/31/2015