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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.orci/ehd <br />PUMP INSPECTION CHECK LIST <br />Address: F. 3-1006e 136-10 <br />Permit#: 00 .1 2,q-11.3 Inspection Date: 1779-/ U2, <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes N No Li NA Li <br />Casing extends at least 12" above grade Yes ,M No Li NA Lii <br />Casing extends at least 1" above pedestal Yes <br />Yesg <br />No NA LI <br />Free of cracks/contiguous with annular seal No Li NA Li <br />Graded to allow drainage away from casing Yes IN No Li NA LI <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes No LI NA Li <br />Seal between all pipe columns and casing Yes Rt No n NA Li <br />Sounding tube/air vents sealed properly Yes RII No Li NA LI <br />Chlorination port available and sealed properly Yes NI 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 LI NA ta <br />Adequately installed check valve or BFP device Yes'N No Elil NA Li <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yek1 No LI NA Li <br />Air gap of at least 6" (same as pipe diameter) ,Yessgr No p NA Li <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes' k No Li NA Li <br />Well/Pump free from excessive vegetation Yes 5v- No Li NA Li <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes RI—No <br />Yes <br /> <br /> Li <br />No I I If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future <br />Photograph taken and attached to record Yes Li No_N <br />OTHER: <br />Comments: 77 , e et) cui Sck <br />_ <br />Inspected By: <br />/ <br />k $ . Ki <br />. 77,4----- <br />Syt-, Title: Jr, R 2/5 <br />Received By: Date: — <br />EH-4200- 8/31/2015