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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.sjgov.org/ehd <br />PUMP INSPECTION CHECK LIST <br />Address: <br />"7 5' reek.--,-, /9-1.;1 C/se•li ) 'ivii th e/c 73/ <br />Permit#: <br />Le Poc) .3 7 c <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 ra. No LII NA <br />Casing extends at least 12" above grade Yes rt No NA <br />Casing extends at least 1" above pedestal Yes Ei,- No NA <br />Free of cracks/contiguous with annular seal Yes II No LII NA <br />Graded to allow drainage away from casing Yes Fr No NA LI <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes a No LI NA LI <br />Seal between all pipe columns and casing Yes No I I NA <br />Sounding tube/air vents sealed properly Yes rq' 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 Ti- No LI NA LI <br />Adequately installed check valve or BFP device Yes t. No LI NA LI <br />Any cross connections? (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes 111111 No LI NA1174- <br />Air gap of at least 6" (same as pipe diameter) Yes LII No LII NA Ff' <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes El No LI NA LI <br />Well/Pump free from excessive vegetation Yes No LI NA LI <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes Lk No LI <br />If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes L No LI <br />Photograph taken and attached to record Yes Pi No LI <br />OTHER: <br />Comments: <br />Inspected By: (,,, , ' Title: 41,,---'1i -jc, ,--.7, , <br />Received By: Date: <br />EH-4200- 8/31/2015