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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.orq/ehd <br />PUMP INSPECTION CHECK LIST <br />Address: 5_5,, 3 AA l L e_1,7 _____i_oc.„.k.....to 0 <br />I <br />Permit#: w poo Li (.?s- <br />Comments/Measure ri-nn <br />Date: <br />572t--17z 1 <br />espnetsctiion <br />Parameter/Standard Meets SJC Standards? Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes N(No LI _ NA LI <br />Casing extends at least 12" above grade Yes IN No NA n <br />Casing extends at least 1" above pedestal Yes Ni No Lii_ NA LII _ <br />Free of cracks/contiguous with annular seal Yes g No NA I I <br />Graded to allow drainage away from casing Yesl i No Lii NA <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes St No LII NA_ LII _ <br />Seal between all pipe columns and casing Yes Ri No NA LII <br />Sounding tube/air vents sealed properly Yes' No NA LII <br />Chlorination port available and sealed properly Yes1/411E1 No LII NA 17 <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 gl No Ill NA I I <br />Adequately installed check valve or BFP device YesV1 No Lii NA <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes LII No LI NA FYI <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 No NA n <br />Well/Pump free from excessive vegetation Yes No NA LI <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes y No ElI <br />If no is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes I'A No n <br />Photograph taken and attached to record Yes Ir No <br />OTHER: <br />Comments: p <br />045 ‘ <br />Inspected By:` Cd-r7i9- 0`.-- 7/1-c5i("0-,1 Title: Af P-S <br />Received By: Date: 51 L1/20 l4 <br />EH-4200- 8/31/2015