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Inspected By: <br />Received By: <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1 868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjqov.orgiehd <br />PUMP INSPECTION CHECK LIST <br />Address: <br />(7t-in i.nc 12-d Peirl:;°1/49° /5 lftf <br />Inspection ate: <br />5/1 7•17-1 <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes M NoLIj NA Il <br />Casing extends at least 12" above grade Yes M NoEl NA [ I <br />Casing extends at least 1" above pedestal Yes t)C No El NA r7 <br />Free of cracks/contiguous with annular seal Yes .% No NA n <br />Graded to allow drainage away from casing Yes )C NoEl NA <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes NoEl NA <br />Seal between all pipe columns and casing Yes r75, No fl NA LII <br />Sounding tube/air vents sealed properly Yes No El NA 111 <br />Chlorination port available and sealed properly Yes No El NALI <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 LI No El NA'gl <br />Adequately installed check valve or BFP device Yes 54. No 111 NA I I <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes 111 No NA <br />Air gap of at least 6" (same as pipe diameter) Yes No 111 NA <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes 11 No El NA <br />Well/Pump free from excessive vegetation Yes No I I 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 IX No <br />Photograph taken and attached to record Yes \71' No <br />OTHER: <br />Comments: <br />Po,s5 <br />Title: fi-ItiS <br />Date: 5/1 <br />EH-4200- 8/31/2015