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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.sjgov.org/ehd <br />PUMP INSPECTION CHECK LIST <br />Address: Li 3y /vtior„d„ , _ s_kock___A w) <br />"cl/ <br />Permit#: w pooq (az Inspection Date: <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yesi No NA LI e* S46-01 <br />Casing extends at least 12" above grade Yes r: No LI NA n <br />Casing extends at least 1" above pedestal Yes q No Lii NA <br />Free of cracks/contiguous with annular seal Yes'll No Lii NA LII <br />Graded to allow drainage away from casing YesiStf No LII NA E <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes kl No NA <br />Seal between all pipe columns and casing Yes .x., No NA LII <br />Sounding tube/air vents sealed properly Yes1 No LIII NA <br />Chlorination port available and sealed properly Yes \A. No NA LII <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 ')! No NA n <br />Adequately installed check valve or BFP device Yes f:4 No 7 NA I I <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes No NA <br />Air gap of at least 6" (same as pipe diameter) Yes No NA 1!1- <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes-M No LI NA <br />Well/Pump free from excessive vegetation Yes 7 No NA I I <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes V No LII <br />If no is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future YesiZ No j <br />Photograph taken and attached to record Yes 14 No <br />OTHER: <br />Comments: n <br />r.s . <br />Inspected By: 10.-- A ___, rt s 1414,_ Title: <br />Received By: Date: 57g V /2-0 Z I <br />EH-4200- 8/31/2015