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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 />Address:l 1 t ,... jp 3 m ,c1( , <br />i Le- 6rbfre_ te--JI <br />o a; <br />W <br />Permit#: <br />00117-0 11 S' <br />Inspection Date: <br />b /Vh'Z' I <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes'J No NA Lii <br />Casing extends at least 12" above grade Yesl% No LIII NA LI <br />Casing extends at least 1" above pedestal Yes PA No NA LI <br />Free of cracks/contiguous with annular seal Yes1-61. No LI NA LI <br />Graded to allow drainage away from casing Yes-144 No LI NA LI <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes" No NA ri <br />Seal between all pipe columns and casing Yesil, No ri NA <br />Sounding tube/air vents sealed properly YesN1 No NA LI <br />Chlorination port available and sealed properly Yes)‘I, No Lii NA I I <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] No NA LII <br />Adequately installed check valve or BFP device Yesy No NA I I <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes No LI NA-Nti <br />Air gap of at least 6" (same as pipe diameter) Yes No LII NA q, <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yeslql No ri NA LI 1 /1 S i-te,J_ <br />Well/Pump free from excessive vegetation Yes'5IC No LI NA LI <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-M No <br />Photograph taken and attached to record Yes-IS No LI <br />OTHER: <br />Comments: <br />e04 S <br />Inspected By: /-...c.)0*-,C( 0"-- A -C---;a43 k •I\N. Title: (2--e—E1— <br />Received By: Date: 6 /Q..- kJ ez..,.. z_ / <br />EH-4200- 8/31/2015