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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.org/ehd <br />PUMP INSPECTION CHECK LIST <br />Address: Permit#: Inspection Date: <br />S 2 (kvL� Z6 ,1le_ 2 -di 2 7 Chi' V/A, 6 17127 <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br />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 />Yes <br />Seal between all pipe columns and casing <br />Yes <br />Sounding tube/air vents sealed properly <br />Yes <br />Chlorination port available and sealed properly <br />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 <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 />Ye <br />Air gap of at least 6" (same as pipe diameter) <br />Ye <br />MAINTENANCE: <br />Well/Pump visible and protected from dama e <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 />��JI��I�:l■I <br />NO== <br />■ <br />•■ <br />WE <br />No NAU <br />No F1 NA F1 <br />No F1 NA F1 <br />Non NA F1 <br />No INA <br />No 7 INA <br />■110=1111118M <br />■ff • ■' ►'4, <br />No El INA❑ <br />No I—I INA F-1 <br />Yes L29 No U <br />Yes [S No ❑ If 'no' is selected, attach an accurate map to permit <br />Yes T-11 No Incl <br />IlnsDectedBV: I\ry-lv-,. (Title: ru I <br />Received <br />Date: <br />EH -4200- 8/31/2015 <br />