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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.sjqov.org/ehd <br />PUMP INSPECTION CHECK LIST <br />Address: !, ,--- - - _ <br />i 1 C / 4'i (;.t-t,b; c„-v ii-/-u4, A( h/tie4.: t ,i ';_/j-s' <br />Permit: 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 ITT , No NA LI <br />Casing extends at least 12" above grade Yes ID No NA LI <br />Casing extends at least 1" above pedestal Yes Z No LI NA LI <br />Free of cracks/contiguous with annular seal Yes D No LI NA LI <br />Graded to allow drainage away from casing Yes 7 No LI NA LI <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes Ely No LI NA LI <br />Seal between all pipe columns and casing Yes v No LI NA LII <br />Sounding tube/air vents sealed properly Yes 0 No LI NA LI <br />Chlorination port available and sealed properly Yes E 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 IV/ No LI NA 1-1 <br />Adequately installed check valve or BFP device Yes Fr No LI NA LI <br />Any cross connections? (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes LI No LI NA I <br />Air gap gap of at least 6" (same as pipe diameter) Yes LI No LI NA Iv( <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes [Ti / No LI NA LI <br />Well/Pump free from excessive vegetation Yes 11 No LI NA LI <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes Fr <br />Yes Tr <br />No LII <br />No LI If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future <br />Photograph taken and attached to record Yes g No LI <br />OTHER: <br />Comments: <br />Inspected By: rire,,,i, 5 ( 0 (0' a•-za (0‘ 4: 2. Title: f17/ <br />Received By: Date: <br />EH-4200- 8/31/2015