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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.sjciov.orgiehd <br />PUMP INSPECTION CHECK LIST yoftc6b 11 S/2 LI/74 <br />Addrest: ,--60 so 47, 410 ; e\.4..._ ie...„4 to 47; Permit#. <br />tot/PO Oil/ V V 3 <br />Inspecti Date: <br />5// M <br />Parameter/Standard 4eets SJC Standards? Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes g No P1 NA LII <br />Casing extends at least 12" above grade Yes r›( No NA LI <br />Casing extends at least 1" above pedestal Yes T71 No P1 NA <br />Free of cracks/contiguous with annular seal Yes14 No LI NA <br />Graded to allow drainage away from casing Yes1 No P1 NA LI <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes g No P1 NA <br />Seal between all pipe columns and casing Yes y No LI NA LII <br />Sounding tube/air vents sealed properly Yes 14 No P1 NA <br />Chlorination port available and sealed properly Yes X No NA LI <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 [71 No P1 NA <br />Adequately installed check valve or BFP device Yes' Y; No III NA 7 <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes174 No P1 NA H <br />Air gap of at least 6" (same as pipe diameter) Yes I I No NA X <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes K No E NA <br />Well/Pump free from excessive vegetation Yes-47 No NA 7 <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Ye§-i i No 7 <br />If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes g No P1 <br />Photograph taken and attached to record Yes 17 No <br />OTHER: <br />Comments: Toss <br />Inspected By: 0-/-2-0•--- Afar" /4-4- (P..- <br />t <br />Title: r e t 0) <br />Received By: Date: 6 /a Li /g,v 2, I <br />EH-4200- 8/31/2015