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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: i , <br />A1. ,i)evr,es,eci zocc Permit#: <br />1,0froo Y7z”? Inspectio5 Date: <br />Parameter/Standard Meets SJC Standards? Comments/Measurenfents/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes No R(NA LII <br />Casing extends at least 12" above grade Yes No I ,,,r NA Lii CX'' CA.r <br />Casing extends at least 1" above pedestal Yes LII No 0 NA <br />Free of cracks/contiguous with annular seal Yes Lii No I I NA n <br />Graded to allow drainage away from casing Yes LI No Eli NA LII <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes Fl No NA LI <br />Seal between all pipe columns and casing Yes rf No LII NA LII <br />Sounding tube/air vents sealed properly Yes Liii No NA Fr <br />Chlorination port available and sealed properly Yes --/ No NA 7 <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 V1 No LI NA LI <br />Adequately installed check valve or BFP device Yes No LII NA LI <br />Any cross connections? (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes LII No [71 NA LI <br />Air gap of at least 6" (same as pipe diameter) Yes No NA ri <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes v: No NA LI <br />Well/Pump free from excessive vegetation Yes '-' No NA 7 <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes 7‘ No <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 Yes I-4' No LII <br />OTHER: <br />Cornments: <br />Inspected By: "111 I '‘ Title: 5 fr- <br />Received By: By: Date: <br />EH-4200- 8/31/2015