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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.orq/ehd <br />PUMP INSPECTION CHECK LIST <br />Address: •Permit#: <br />1111/Z- ft1 61/Y A'z S-'10 h 69 9(211 , u (1' L' <br />Inspection Date: <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes No LI NA I I <br />Casing extends at least 12" above grade Yes No NA <br />Casing extends at least 1" above pedestal Yes III No NA LI <br />Free of cracks/contiguous with annular seal Yes No NA <br />Graded to allow drainage away from casing Yes II No NA <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes E No LI NA LI <br />Seal between all pipe columns and casing Yes No LI NA LI <br />Sounding tube/air vents sealed properly Yes No LI NA LII <br />Chlorination port available and sealed properly Yes LI 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 LII <br />Adequately installed check valve or BFP device Yes LI No LI NA Lii <br />Any cross connections? (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes LI No LI NA Fr <br />Air gap of at least 6" (same as pipe diameter) Yes LI No LI NA LI <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes II No LI NA LI <br />Well/Pump free from excessive vegetation Yes Lii No LI NA LI <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes LI No LI <br />If no is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes LI No <br />Photograph taken and attached to record Yes LI No LII <br />OTHER: <br />Comments: <br />Inspected By: -C.01."./j c CL; tcci-v2e-, ci)-6-1.- Title: Ell ,4-5e,;`..51-7-4. f <br />Received By: Date: <br />EH-4200- 8/31/2015