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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.slgov.org/ehd <br />PUMP INSPECTION CHECK LIST <br />Address: Permit#: Inspection Date: <br />7401 Cox Rd., Linden WP0041945 1/3/22 <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal 2'x2'x4" minimum <br />Casing extends at least 12" above grade <br />Casing extends at least 1" above pedestal <br />Free of cracks/contiguous with annular seal <br />Graded to allow drainage away from casing <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes <br />Seal between all pipe columns and casing Yes <br />Sounding tube/air vents sealed properly Yes <br />Chlorination port available and sealed properly Yes <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 <br />Adequately installed check valve or BFP device Yes <br />Any cross connections? (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes <br />Air gap of at least 6" (same as pipe diameter) Yes <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes <br />Well/Pump free from excessive vegetation 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 />m <br />m <br />m <br />No❑ INA El <br />NoF-1 INAn <br />`IL■1 `ME <br />.■M■ <br />Yes No ❑ <br />Yes ® No ❑ If 'no' is selected, attach an accurate map to permit <br />Yes IRI No I-1 <br />Ilnspected BY: /1/ L'I_C� ,�;1lITitle: 11�i V_ (Zl✓ " C_ I <br />Received <br />Date: <br />EH -4200- 8/31/2015 <br />