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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.orA/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: j Permit#: Inspection D te: <br /> f j�2 ;2�� 72_T <br /> Parameter/Standard Meets SJC Standards? Comments/Measurem tsl <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal 2'x2'x4" minimum) Yes V1 No ❑ NA❑ <br /> Casing extends at least 12° above grade Yes © No ❑ NA❑ <br /> Casing extends at least 1" above pedestal Yes ( No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes No ❑ NA❑ <br /> Graded to allow drainage awa from casing Yes 0 No ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes El No ❑ NA ❑ <br /> Seal between all pipe columns and casing Yes'❑ No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑ NA R1 <br /> Chlorination port available and sealed properly Yes 0 No [:] ,NA <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 Yes ® No ❑ NA❑ <br /> Adequately installed check valve or BFP device Yes [D No ❑ NA❑ <br /> AD cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No ❑ NA F] <br /> Air gap of at least 6" (same as pipe diameter) jYes ❑ No ❑ INA <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes [Z No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes No ❑ NA El <br /> MISCELLANEOUS: <br /> Permit draWng represents actual location of well Yes g No ❑ <br /> Permit drawing sufficient to locate well in future Yes No ❑ If'no'is selected,attach an accurate man to permit <br /> Photograph taken and attached to record Yes ❑ No ❑ <br /> OTHER: <br /> Comments: <br /> Ins ected 8y Titie• i <br /> Received By: Date: <br /> EH-4200- 8/31/2015 <br />