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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 />7k; c 6 bk,' A',11e ij ( GI e- 61) IC 3 = 1 V 1 <br />Permit#: <br />S R oc.' i 7 I Z <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 El' No LI NA LI <br />Casing extends at least 12" above grade Yes ri No LIII NA LI <br />Casing extends at least 1" above pedestal Yes ri- t No LI NA LIII <br />Free of cracks/contiguous with annular seal Yes cl No LI NA LI <br />Graded to allow drainage away from casing Yes IT7( No LI NA LI <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes a No Eli NA LI <br />Seal between all pipe columns and casing Yes <br />,- <br />i' No LI NA LI <br />Sounding tube/air vents sealed properly Yes 1171/ No LI NA LI <br />Chlorination port available and sealed properly Yes 71/ 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 Fr No NA LI <br />Adequately installed check valve or BFP device Yes Er 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 LIII NA M--- <br />Air gap of at least 6" (same as pipe diameter) Yes LI No LI NA 1-V <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes [a- No LIII NA LI <br />Well/Pump free from excessive vegetation Yes Er No NA LI <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes 2 No LI <br />If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes Ft No <br />Photograph taken and attached to record Yes Er No LI <br />OTHER: <br />Comments: <br />Inspected By: r-c----,,,,Li , j ( , (.5:„.„. (e. , z__ , <br />Title. t- ci 5 <br />Received By: Date: 3j i/ /2s:-.2 ( <br />EH-4200- 8/31/2015