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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.orgiehd <br />PUMP INSPECTION CHECK LIST <br />Address: 40 0 1 /v. cimirleivi is ej ti• iii cLto Permit#: <br />A449°10/ a_-6 <br />Inspection Date: <br />5/e WZ5Z./ <br />Parameter/Standard <br />i <br />Meets SJC Standards? Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes 15 No NA <br />Casing extends at least 12" above grade Yes 1..c No LI NA LI <br />Casing extends at least 1" above pedestal Yes g No NA III <br />Free of cracks/contiguous with annular seal Yes-14' No LI NA LI <br />Graded to allow drainage away from casing Yes 171 No LII NA LI <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes S No NA LI <br />Seal between all pipe columns and casing Yesil No LI NA LI <br />Sounding tube/air vents sealed properly Yes 'K No NA <br />Chlorination port available and sealed properly Yeslf No NA <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 liii No NA4 <br />Adequately installed check valve or BFP device Yes' g No NA <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes I I No 7 NA VI <br />Air gap of at least 6" (same as pipe diameter) Yes No NA <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes No NA LII <br />Well/Pump free from excessive vegetation Yes171- No 7 NA Lii <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well YealCe No LII <br /> If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes 4Z1 No I I <br />Photograph taken and attached to record Yes ty No LI <br />OTHER: <br />Comments: <br />. i <br />n <br />rOL-S 5 <br />Inspected By: 1 Ope:/ 0... A-G/LIKA4‘0-- Title: g ry-s <br />Received By: Date: 54 /-/-t7 - I <br />EH-4200- 8/31/2015