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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: %,yaw, si-go i. o0q ehd <br />PUMP INSPECTION CHECK LIST <br />Address: <br />penylito; 1 Inspection Pate. <br />PararneteriStandard <br />Meets SJC Standards? �ornrnents=easurerndntsf <br />Recommendations <br />CEMENT PEDESTAL, <br />Dimensions of surface seal (2'x2'x4" minimum', <br />Yes -17 l <br />No <br />NA M <br />Casing extends at least 12' above grade <br />Yes <br />No <br />NA <br />Casing extends at least 14 above pedestal <br />Yes <br />No E <br />Free of cracksicontiguous with annular seal <br />1Yes <br />No 7 <br />SNA <br />Graded to allow drainage away from casin <br />iYes El <br />No [I <br />NA <br />SANITARY SEAL: <br />Well is sealed between pump and casing <br />No F-1 <br />NA <br />—Yes <br />Seal between all pipe columns and casin <br />IYes Ej <br />No <br />NAEJ <br />Sounding tube/air vents seaied properly <br />Yes[] <br />No <br />NA <br />Chlorination port available and sealed properly <br />. . .. .......... <br />Yes Ej_j <br />No <br />NA r-1 <br />. <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 Fl, <br />No <br />NA <br />'Id <br />cross connections (ex: chemical feeders <br />Looked to distribution system/ag flood irrigation <br />from domestic sup ply)Yes <br />INo El <br />INA <br />Air gap of at least 6' (same as pipe diameter) <br />lyes F] <br />No E] <br />INA <br />MAINTENANCE: <br />protected from damage <br />Well/Pqn22visible grid ro <br />Yes 0 <br />1jNo F NA <br />-1 El <br />Well/Pumpfree from excessive veget tion <br />Yes <br />No NA 71 <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well <br />IYes No <br />lf'no'is set)ctad, attac,,,, an accurate map to perrnit <br />t sufficienate well in future <br />Permit drawing locate o t <br />11 I 11 I 11 <br />Yes No <br />Tyes <br />I , to record <br />Photograph taken a . nd attached <br />No Q <br />OTHER: <br />Comments: <br />AsPeciLed By:, <br />Received By: <br />Tule. ,A;�" <br />Date - <br />EH -4200- W3112015 <br />