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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: i 0 0 1 N peetic.s 0 in re_ j 1 Lio 01:1- Permitt, <br />WC 0 1-iicS3 <br />0 Inspection Date: 6,/Q1/74 <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes-7f- No LII NA <br />Casing extends at least 12" above grade YeslY, No I I NA <br />Casing extends at least 1" above pedestal Yes J' No H NA <br />Free of cracks/contiguous with annular seal Yes g No LII NA H <br />Graded to allow drainage away from casing YesI)4,, No I I NA LI <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes If No H NA <br />Seal between all pipe columns and casing Yes -gi No LI NA LII <br />Sounding tube/air vents sealed properly Yes I5V No H NA <br />Chlorination port available and sealed properly Yes I71. No LI 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\Wf No H NA <br />Adequately installed check valve or BFP device Yes)41 No H NA <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes 7 No IA NA .frcr <br />Air gap of at least 6" (same as pipe diameter) Yes 7 No I ] NA <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yesilq No H NA LI <br />Well/Pump free from excessive vegetation Yes rt• No H NA n <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yel• ,41- No <br />If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes9 No H <br />Photograph taken and attached to record Yes ilSr No <br />OTHER: <br />Comments: n <br />roLs <br />, 1 <br />Inspected By: OLY- I N.._ S1441 Title: /2--F/9- 3 <br />Received By: Date: (12 t / Z2 2-- I <br />EH-4200- 8/31/2015