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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 org/ehd <br />PUMP INSPECTION CHECK LIST G,.... 3 Address: Cisjh-{--41;(e_ l e: e-d -L-V—toe, / <br />1 Perm it#• <br />WooLi 1 99-D Inspection Date: <br />5121//2"/ <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes -1;41. No ri NA LII <br />Casing extends at least 12" above grade Yes 1% No C NA <br />Casing extends at least 1" above pedestal Yes g No LII NA <br />Free of cracks/contiguous with annular seal Yes M No LIII NA <br />Graded to allow drainage away from casing Yes '< No I-1 NA LII <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes 17( No LII NA LI <br />Seal between all pipe columns and casing Yes 1Y1 No NA <br />Sounding tube/air vents sealed properly Yes 21 No NA LII <br />Chlorination port available and sealed properly Yes i'. No LII 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' gr No NA LIII <br />Adequately installed check valve or BFP device Yesl?C- 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 LII No NA spl: <br />Air gap of at least 6" (same as pipe diameter) Yes No NA <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes'il. No LI NA LII <br />Well/Pump free from excessive vegetation Yes 11, No NA <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes 4( No LI <br />If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes rg. No <br />Photograph taken and attached to record Yes l'?1. No LI <br />OTHER: <br />Comments: n <br />to-s. <br />Inspected By: )01-rie"--1 7r-21'>5/4gi_0.--_ Title: <br />Received By: Date: C / 2, Li frz../ <br />EH-4200- 8/31/2015