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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.orq/ehd <br />PUMP INSPECTION CHECK LIST <br />Address: /),,z <br />1 Lel , ( tl (i5-2 tj 2 <br />Perrrlit#: <br />1,0 i.) (.."(1 I:: , <br />Inspection Date: <br />212 <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes ,, No NA LII <br />Casing extends at least 12" above grade Yes I v f No LII NA <br />Casing extends at least 1" above pedestal Yes Ff No NA <br />Free of cracks/contiguous with annular seal Yes F-7 No NA 1111111 <br />Graded to allow drainage away from casing Yes El No NA <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes IT:d' No NA pi <br />Seal between all pipe columns and casing Yes 1 yr No LII NA -- <br />Sounding tube/air vents sealed properly Yes wr No NA ri <br />Chlorination port available and sealed properly Yes Fr No NA [ I <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 IE.- No NA <br />Adequately installed check valve or BFP device Yes ITr No LII NA 7 <br />Any cross connections? (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes No NA V- <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 I No LIII NA LII <br />Well/Pump free from excessive vegetation Yes 7-- No NA I I <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes Mr No <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 rvi No <br />OTHER: <br />Comments: <br />‘, Inspected By: .f 5 \ ":,") .-‘4 -14,1L, Title: <br />Received By: Date: 1,A 'Th\ 1:;;;C\ <br />EH-4200- 8/31/2015