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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.siciov.orgiehd <br />PUMP INSPECTION CHECK LIST <br />Address: 1 9 1 1.1 -;,—, <br />L- ei9ircf - /14 ;lc re-d i 1-;itdeA, <br />Permit#: <br />/WOO Li i 50 <br />Inspection Date: <br />5/t 7_4 <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes•V No NA <br />Casing extends at least 12" above grade Yesq No LI NA <br />Casing extends at least 1" above pedestal Yes M No I I NA <br />Free of cracks/contiguous with annular seal Yes5t No LI NA IA <br />Graded to allow drainage away from casing Yes I./ No LIII NA pi <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes g No H NA <br />Seal between all pipe columns and casing Yes Kr No LIII NA LII <br />Sounding tube/air vents sealed properly Yes FA No NA LI <br />Chlorination port available and sealed properly Yes )(I No LIII NA LII <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 X No LII NA LII <br />Adequately installed check valve or BFP device Yes -I4 No LII NA I I <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes H No LII NA M <br />Air gap of at least 6" (same as pipe diameter) Yes LI No I I NA 14: <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes rgi. No I I NA <br />Well/Pump free from excessive vegetation Yesii_ No I I NA <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes.'ff' No LI <br />If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes FA No <br />Photograph taken and attached to record Yes II. No I I <br />OTHER: <br />COkSS <br />Cornments: <br />Inspected By: eiri‘V 4-4il-3 sK-Ce4k_ Title: P—Fht—S <br />Received By: Date: .5// 7/ 7-.9 -? ( <br />EH-4200- 8/31/2015