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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.or /q ehd <br />PUMP INSPECTION CHECK LIST <br />Address: c Permit#: Inspection Dake: <br />�8Z1� �. 3Yv�-C S� L�� e� WfCom ments/Measurements/ <br />oo`1Zvy 12/1��Z/ <br />Parameter/Standard Meets SJC Standards? Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) <br />Ye <br />Casing extends at least 12" above grade <br />Ye <br />Casing extends at least 1" above pedestal <br />Ye <br />Free of cracks/contiguous with annular seal <br />Ye <br />Graded to allow drainage away from casing <br />Ye <br />SANITARY SEAL: <br />Well is sealed between pump and casing <br />Ye <br />Seal between all pipe columns and casing <br />Ye <br />Sounding tube/air vents sealed properly <br />Ye <br />Chlorination port available and sealed properly <br />Ye <br />SAMPLE TAP AND BACKFLOW PREVENTION: <br />Non -threaded sample tap between well head and <br />check valve or within 3' of well head <br />Yes <br />Adequately installed check valve or BFP device <br />Yes <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) <br />Yes <br />Air gap of at least 6" (same as pipe diameter) <br />Yes <br />MAINTENANCE: <br />Well/Pump visible and protected from damage <br />Yes <br />Well/Pump free from excessive vegetation <br />Yes <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well <br />Permit drawing sufficient to locate well in future <br />Photograph taken and attached to record <br />OTHER: <br />Comments: <br />a B ■1G ° AIR <br />.■E■ <br />m■1M <br />• ■ m <br />• ■ m <br />►��M <br />Yes N No U <br />Yes'K No ❑ If'no' is selected, attach an accurate map to permit <br />Yes F] No <br />Inspected By: J (/l S ( Title: �>r <br />J5 <br />Received By: -�� Date: 2 2 <br />EH -4200- 8/3112015 <br />■ <br />• ■■■EN <br />►� <br />11►10�■Il`I�■I <br />a B ■1G ° AIR <br />.■E■ <br />m■1M <br />• ■ m <br />• ■ m <br />►��M <br />Yes N No U <br />Yes'K No ❑ If'no' is selected, attach an accurate map to permit <br />Yes F] No <br />Inspected By: J (/l S ( Title: �>r <br />J5 <br />Received By: -�� Date: 2 2 <br />EH -4200- 8/3112015 <br />