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SAN JOAQUIN COUNTY <br />ENVIHONMEN I AL HEAL I H DEPAH I MEN I <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.siqov.org/ehd <br />PUMP INSPECTION CHECK LIST <br />Address: <br />12 <br />u <br /> 14 L( 11 i foe . , <br />Permit#9: <br />P0 Ifb y t '22 <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 LI No R '/NA LI <br />Casing extends at least 12" above grade Yes Li No IG NA LII <br />Casing extends at least 1" above pedestal Yes Li No DI/ NA Lii <br />Free of cracks/contiguous with annular seal Yes Li No Illg/NA LI <br />Graded to allow drainage away from casing Yes Li No NA Li <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes 1Yr/No Li NA <br />Seal between all pipe columns and casing Yes IV / No Li NA Li <br />Sounding tube/air vents sealed properly YesIng/ No Li NA LI <br />Chlorination port available and sealed properly Yes Ell No LII NA LII <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 f [INo 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 Li NA t <br />Air gap of at least 6" (same as pipe diameter) Yes No NA <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes EjNo Li NA Li <br />Well/Pump free from excessive vegetation Yes No Li NA Li <br />MISCELLANEOUS: <br />Yes <br />If 'no' is selected, attach an accurate map to permit <br />Permit drawing represents actual location of well <br />Permit drawing sufficient to locate well in future Yes Er No Li <br />Yes ErNo Li Photograph taken and attached to record <br />OTHER: <br />Comments: 1 <br />- cc.u4,A\' 't.i.(-S\f- i , \. k v <br />i, Nark,/ cctiA ilE ct, (,_u ,. 1 <br />Inspected By: Vi„,r\ii,c.,C,., (..4 m1_4, I 40‘..11._ Title: \I ASiic <br />ReceivedReceived By: Date: gi 7. 2-PL) <br />EH-4200- 8/31/2015