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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.siqov.org/ehd <br />PUMP INSPECTION CHECK LIST <br />0( <br />Address: - <br />- 5 t <br />% •1 /-6 /An dex (We)) i <br /> k J ) <br />Pe <br />LA <br />rm <br />/ <br />it# <br />p <br />:.. <br />ool-1 o 36,2 <br />Inspection Date: 5/1 ItZtri,[ ) <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes sM No H NA LI <br />Casing extends at least 12" above grade Yes "'"% No NA <br />Casing extends at least 1" above pedestal Yes' y1 No H NA <br />Free of cracks/contiguous with annular seal Yes1)4 No LI NA LI <br />Graded to allow drainage away from casing YesV No H NA LII <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes-til No LI NA I I <br />Seal between all pipe columns and casing Yes-M No LII NA I I <br />Sounding tube/air vents sealed properly Yesyerl No NA LII <br />Chlorination port available and sealed properly Yesliall No H 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 LI No I I NANit <br />Adequately installed check valve or BFP device YesY No NA <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes No LII NAli <br />Air gap of at least 6" (same as pipe diameter) Yes No H NA --7r <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes lA No H NA <br />Well/Pump free from excessive vegetation Yes 1. No H NA <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' S No H <br />Photograph taken and attached to record Yes\1- No <br />OTHER: <br />()I <br />Comments: _ <br />, <br />C',. Inspected By: A -Cory Vaa Title: Pe-145 <br />Received By: Date: 5711—i -7A07/ <br />EH-4200- 8/31/2015