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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.org/ehd <br />PUMP INSPECTION CHECK LIST <br />Address: <br />'P.( ) j t (-.64-1"L .•k(', (4Lji7/7 <br />Permit#: <br />(-''--PC ' 3 '-/ () 6, <br />Inspection Date: <br />i / .57--z. t <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes HI No NA <br />Casing extends at least 12" above grade Yes F No NA <br />Casing extends at least 1" above pedestal Yes 2 No NA <br />Free of cracks/contiguous with annular seal Yes 2- No LII NA <br />Graded to allow drainage away from casing Yes F(No LII NA <br />SANITARY SEAL: <br />Well is sealed between pump and casing <br />, <br />Yes No NA LI <br />Seal between all pipe columns and casing Yes 2 No LI NA LI <br />Sounding tube/air vents sealed properly Yes / No NA <br />Chlorination port available and sealed properly Yes —1,1' No NA <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 FT No NA <br />Any cross connections? (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes No NA E <br />Air gap of at least 6" (same as pipe diameter) Yes LI No LI NA <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes rt No NA LI <br />Well/Pump free from excessive vegetation Yes i- No NA LI <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes .:E.-- No LI <br />If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes E[ No <br />Photograph taken and attached to record Yes V No LI <br />OTHER: <br />Comments: <br />, <br />Inspected By: tre,1 4 ; 3 L , ( , -- A.-L-c L , 4. Title: 6, i_i A__5,,,,f, . l <br />Received By: Date: / /9-1/11 C' <br />EH-4200- 8/31/2015