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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 />C Z (2i t- /.57/1 A7C ,4i, -.1,,,/a-, (,- 9f -2,5 <br />Permit#: <br />us',.iu,'' c, Lk -1, <br />Inspection Date: <br />--i. i 3 t <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimens ons of surface seal (2'x2'x4" minimum) <br />, <br />Yes V No III NA <br />Casing extends at least 12" above grade Yes No NA <br />Casing extends at least 1" above pedestal Yes 7 No LI NA LI <br />Free of cracks/contiguous with annular seal Yes 7 No NA LI <br />Graded to allow drainage away from casing Yes rl No LI NA LI <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes No LI NA LI <br />Seal between all pipe columns and casing Yes FT/ No LI NA LI <br />Sounding tube/air vents sealed properly Yes R7 No LI NA LI <br />Chlorination port available and sealed properly Yes LI No Lii NA 7LI <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 1-71 <br />Adequately installed check valve or BFP device Yes Il 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 71 NA LI <br />Air gap of at least 6" (same as pipe diameter) Yes I I No LI NA [71 <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes d No LI NA LI <br />Well/Pump free from excessive vegetation Yes 4 No 7 NA LI <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes IN No 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 P71 No Li <br />OTHER: <br />Cornments: <br />Inspected By: - , , c c., Title: — 4 ,4,-- - .-.1-,A , -1- ., c. <br />Received By: Date: 2 (3 f‘7)...-)/ 1 <br />EH-4200- 8/31/2015