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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.siciov.orci/ehd <br />PUMP INSPECTION CHECK LIST <br />Address: <br />q6(.3 Puff -five . -3.% ccv-irn, cia- chava-- <br />Permit#: <br />NP00361c481- <br /> Inspectiop Date: <br />8/5o 119 <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes Er No NA <br />Casing extends at least 12" above grade Yes 2 No LI NA LI <br />Casing extends at least 1" above pedestal Yes No LI NA Lii <br />Free of cracks/contiguous with annular seal Yes LI No 17/ NA LII --tree qcowic ,9 -k\vouqk -khe <br />Graded to allow drainage away from casing Yes LI No R1/NA LI c_x-c7tCre-S <br />SANITARY SEAL: , <br />Well is sealed between pump and casing Yes Er No LII NA LI <br />Seal between all pipe columns and casing Yes 12' No El NA LI <br />Sounding tube/air vents sealed properly Yes Er No LI NA LI <br />Chlorination port available and sealed properly Yes FX No LI 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 121 No LI NA LI <br />Adequately installed check valve or BFP device Yes I-7/ No LI NA LI <br />Any cross connections? (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes LIII No LI NA I-'' <br />Air gap of at least 6" (same as pipe diameter) Yes LI No LI NA F <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes EX No LI NA LI <br />Well/Pump free from excessive vegetation Yes M' No LI NA LI <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes D'INlo LI <br />If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes a No LI <br />Photograph taken and attached to record Yes ErNo LI <br />OTHER: <br />Comments: <br />F.deStON '?S con'T\ erek't CriaCka di , -tree Ts 9 rovN3n9 -‘411rov,gh ri-kle Ccack.s <br />- (--)norr:3 up i4r)rouc3 h 9rounck tlexi- ko voe op newepti+ CpcSk'oc:3 , cc cc- ore v--v V <br />1 <br />Inspected By: tWASI 1 na ('AQA-Cir V1 Ass'ftt-of-y\-- Title: tii <br />Received By: Date: <br />EH-4200- 8/31/2015