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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.orgiehd <br />PUMP INSPECTION CHECK LIST <br />Address: <br />32,(3 6,0 7ret:f3 <br />Permit#: <br />peo D )10 lid Inspe9tiV27 <br />r/0 <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes I-f No Li NA Li <br />Casing extends at least 12" above grade Yes rwr No I I NA ri <br />Casing extends at least 1" above pedestal Yes 11 No Li NA Li <br />Free of cracks/contiguous with annular seal Yes M' No Li NA Li <br />Graded to allow drainage away from casing Yes i-i No Li NA Li <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes M No Li NA Li <br />Seal between all pipe columns and casing Yes I-1 No Li NA LII <br />Sounding tube/air vents sealed properly Yes No 11111 NA Li <br />Chlorination port available and sealed properly Yes [7f 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 YesR7fiNo Li NA Li <br />Adequately installed check valve or BFP device Yes I—/ No Li NA Li <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes Li No '71\JA Li <br />Air gap of at least 6" (same as pipe diameter) Yes 11 No Li NA I-11 <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes Fr No Li NA Li <br />Well/Pump free from excessive vegetation Yes 71' No Li NA Li <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes reNo Li <br />If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes I--" <br />Yes 121/No <br />No 1-1 <br />Li Photograph taken and attached to record <br />OTHER: <br />Comments: <br />Inspected By: A414,0"---419 Title: Se- ,le-ria <br />Received By: Date: <br />EH-4200- 8/31/2015