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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: ,,,--- <br />5 225- (46 ),Tip <br />Permit#: Inspection Date: <br />Ly <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes IT No Li NA <br />Casing extends at least 12" above grade Yes V- No Li NA H <br />Casing extends at least 1" above pedestal Yes 1-1 No 1----i NA LI <br />Free of cracks/contiguous with annular seal Yes No Li NA Li <br />Graded to allow drainage away from casing Yes Z No Li NA Li <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes 1-171 No Li NA Li <br />Seal between all pipe columns and casing Yes Tr No Li NA [ I <br />Sounding tube/air vents sealed properly Yes Fr No Li NA LII <br />Chlorination port available and sealed properly Yes 11 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 vr No Li NA Li <br />Adequately installed check valve or BFP device <br />__ <br />Yes V 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 <br />, <br />NA [7-1/ <br />Air gap of at least 6" (same as pipe diameter) Yes Li No Li NA rii <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes Ili No Li NA Li <br />Well/Pump free from excessive vegetation Yes Al/ No Li NA Li <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes TT No Li <br />If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes No ri <br />Photograph taken and attached to record Yes V No Li <br />OTHER: <br />Cornments: <br />' Inspected By: ,1 t'i — Ccv -C•:C.--, /4114:7 Title: <br />Received By: Date: '2-1 2 S- /2P.-z_ 7 <br />EH-4200- 8/31/2015