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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.sjgov.org/ehd <br />PUMP INSPECTION CHECK LIST <br />1 Address:Permi 1 _I 2_0 <br />C, Clq .- h - /II; te le-4, S--toc-K-6 <br />ttt: <br />Comments/Measuremines <br />pnetcstiion.Date: <br />572(-0 i <br />Parameter/Standard <br />/ <br />Meets SJC Standards? Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes' ef No H NA I I -e•ics-41 <br />Casing extends at least 12" above grade Yes hic. No ri NA LI <br />Casing extends at least 1" above pedestal Yes N; No I I NA <br />Free of cracks/contiguous with annular seal Yes [g. No NA <br />Graded to allow drainage away from casing Yes V- No NA ri <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes`9 No NA I I <br />Seal between all pipe columns and casing No NA <br />Sounding tube/air vents sealed properly <br />Yes\4 <br />Yes No NA LI <br />Chlorination port available and sealed properly Yes 9 No LII 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" j No NA ri <br />Adequately installed check valve or BFP device Yes' 54 No NA n <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes No NA Rt <br />Air gap of at least 6" (same as pipe diameter) Yes LII No NA'ql <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes li: No LII NA I I <br />Well/Pump free from excessive vegetation Yes •--(e._ No Lii NA I I <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes N No LI <br />If no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes No <br />Photograph taken and attached to record Yesel No <br />OTHER: <br />Comments: q <br />J(1-C <br />Inspected By: ate-)01/4, 51440e--- Title: KC HS <br />Received By: Date: 5/24/1 <br />EH-4200- 8/31/2015