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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: wvvw.sjoov.orgiehd <br />PUMP INSPECTION CHECK LIST <br />Address: <br />i5- 1.4-L1 1 .6, , L v% &eit, t, uu t tit 4 L) t <br />Permit#: Inspeclion, Date: <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes,rr No Lii NA <br />Casing extends at least 12" above grade Ye,71. No NA LI <br />Casing extends at least 1" above pedestal Yej,1‹—No LI NA LII <br />Free of cracks/contiguous with annular seal Ye?,11- No NA LI <br />Graded to allow drainage away from casing Ye No LI NA LII <br />SANITARY SEAL: <br />Well is sealed between pump and casing Ye?541 No NA <br />Seal between all pipe columns and casing Yescr No LII NA LI <br />Sounding tube/air vents sealed properly Yesir No NA LII <br />Chlorination port available and sealed properly Yest,K 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 LI No NA K. <br />Adequately installed check valve or BFP device Yes .1.----No LI NA LI <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yesti‹—No Lii NA LI <br />Air gap of at least 6" (same as pipe diameter) YesZr No n NA LI <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yesel No LII NA <br />Well/Pump free from excessive vegetation Yese No LI NA LI <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes j1r No LI <br />If 'no is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future YesEr)lo j <br />Yes 4 1 No LI Photograph taken and attached to record <br />OTHER: <br />Comments: <br />Inspected By: 10 - o tk k Title: 5 ¢... a evi c <br />Received By: Date: / 7___ — 2_ — 2. 1 <br />EH-4200- 8/31/2015