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Site Address: 10330 Fairchild Rd, Stockton CA 95215 <br />Date: 12/28/2021 <br />PHOTO # 1 Pump inspection check list. <br />5:; <br />I <br />1 <br />Igo ENVIRONMENTAL HEALTH DEPARTMENT <br />tt 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: wwwsigoy. oro/ehd <br />PUMP INSPECTION CHECK LIST <br />acrackS/contiquous <br />Permiw mspedil, D <br />�C 0.;r42S3S Iz "I <br />Commento/Measuremenis /Parameter/Standard Mees SJC Standarde� Recommendations <br />DESTAL:f surface seal ds at least 12"above rade Yes No ❑ NA ❑ds at least 1" above edestal Yes R No ❑ NA ❑s/contiguous with annular seal Yes 141 INnF NAM <br />vveii is seated between pump and casing Yes V No ❑ NA ❑ <br />Sealbewpipe columns and -casing Yes No ❑ NA ❑ <br />Sounding tube/air vents sealed properly Yes M No ❑ NA ❑ <br />Chlorination ort available and sealed roperly Yes R No ❑ NA ❑ <br />SAMPLE TAP AND BACKFLOW PRFVFNTtnN- <br />Non-threaded sample tap between well head and <br />check valve or within 3' of well head <br />Yes ® <br />No ❑ <br />NA ❑ <br />Adequately installed check valve or BFP device <br />Yes ® <br />No ❑ <br />NA ❑ <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic su I <br />Yes ❑ <br />No ❑ <br />NA <br />Air a of at least 6" (same as i e diameter <br />Yes ❑ <br />No ❑ <br />NA EZ <br />Record ID: WP0042535 <br />EH -4200- <br />8/31/2015 <br />a <br />. Francisco Garcia Ruiz, Environmental Health Specialist Trainee Page 1 of 1 <br />