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SAN.JOAQUIN COUNTY <br /> 2 — �e 4J ENVIRONMENTAL HEALTH DEPARTMENT <br /> 868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> �j7i^51 q Z Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.s'gov.org/ehd <br /> Yz9-G$- G�Z y A.44_ PUMP INSPECTION CHECK LIST <br /> Address: Permit#: ectio Date: <br /> ti-\ z)C_f�' olt_� �3f z <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (extends 2'from <br /> casing) Yes No 0 NA LA dLC-0L_f—, �— <br /> Casing extends at least 12" above grade Yes PO No ❑ NA ❑ <br /> Casing extends at least V above pedestal Yes NoNA ElFree of cracks/contiguous with annular seal Yes ElNo NA ❑ <br /> Graded to allow drainage away from casing Yes ❑ No A NA ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes No ❑ NA ❑ <br /> Seal between all pipe columns and casing Yes No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yes No ❑ NA ❑ <br /> Chlorination port available and sealed properly Yes No ❑ NA ❑ <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 ❑ N o 66�M.Q <br /> Adequately installed check valve or BFP device Yes No ❑ NA ❑ <br /> Cross connections (ex: chemical feeders hooked <br /> to distribution system/ag flood irrigation from <br /> domestic supply) Yes ❑ No NA ❑ <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 4 No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes No ❑ NA ❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes No ❑ <br /> Permit drawing sufficient to locate well in future Yes No ❑ It'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER: <br /> ` Comments: <br /> Inspected By:Aaron Gooderham Title: Registered Environmental Health Specialist <br /> Received By: Date: <br /> EH-4200- 8131/2015 <br />