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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.orq/ehd <br />PUMP INSPECTION CHECK LIST <br />Address: <br />C. 11 <br />r) Ai e ..C:-1-6- , :1 l . ir,it C -q '21-3c:i S/ y. <br />Permit: <br />ttleeu //72/ <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 Er No NA <br />Casing extends at least 12" above grade Yes R,7 No LII NA <br />Casing extends at least 1" above pedestal Yes 1-4 No NA LI <br />Free of cracks/contiguous with annular seal Yes Ff No LI NA LI <br />Graded to allow drainage away from casing Yes 71 No NA LI <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes R-4/ No LI NA LI <br />Seal between all pipe columns and casing Yes Y No LI NA LI <br />Sounding tube/air vents sealed properly Yes [I No LI NA LI <br />Chlorination port available and sealed properly Yes —I No LII 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 17 No LI NA LI <br />Adequately installed check valve or BFP device Yes vr No LII 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 p. <br />Air gap of at least 6" (same as pipe diameter) Yes LI No 7 NA 111 <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes Fr No LI NA LI <br />Well/Pump free from excessive vegetation Yes VI No LI NA LI <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes FrNo LI <br />If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes No LI <br />Photograph taken and attached to record Yes F' No LI <br />OTHER: <br />Comments: <br />Inspected By: 1-.4 ,7 C. 5 (1 .' 61, I, ,, e t 2_ Title: C# <br />Received By: Date: —; (3/ 2 CZ 1 <br />EH-4200- 8/31/2015