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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: <br /> <br />6 (le, ,JI( „Cit ..tict i: & L'et ,5- ZI 5- <br /> <br />2 ,L / <br />Permit#: , <br />LA- (--.C' t f/ c•-• 74, <br />Inspection Date: <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br />Recommendations _ <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes g No LII NA <br />Casing extends at least 12" above grade Yes E No Lii NA LI <br />Casing extends at least 1" above pedestal Yes 171/ No NA LI <br />Free of cracks/contiguous with annular seal Yes RI No LI NA LI <br />Graded to allow drainage away from casing Yes I-* No LI NA LI <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes 121 No LII NA LI <br />Seal between all pipe columns and casing Yes Ff No LI NA LI <br />Sounding tube/air vents sealed properly Yes El/ No LI NA LI <br />Chlorination port available and sealed properly Yes LI No LI NA E <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 6 <br />Adequately installed check valve or BFP device Yes r No LI NA LI <br />Any cross connections? (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes 71 No LI NA LI <br />Air gap of at least 6" (same as pipe diameter) Yes LI No LI NA Ei <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes 71 No LI NA LI <br />Well/Pump free from excessive vegetation Yes Ei , No LI NA LI <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes IV' No LI <br />If no is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes El/ No LI <br />Photograph taken and attached to record Yes pi No LI <br />OTHER: <br />Comments: <br />Inspected By: --/- 44 1 , , (,, _,,,,,,,s ,,A 2 Title: EV (114'5/5tez,t) <br />Received By: Date: -V 27 /2_,.., z / <br />EH-4200- 8/31/2015