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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.sigov.orcilehd <br />PUMP INSPECTION CHECK LIST <br />Address: <br />\ C)\-4 `-` ,c- 0 2.,•(...... \.,1 0 0 ..2:) 9-10 (•,--S:). <br />Permit#: <br />\AVM\ \ <br />lnspec 'on Date: <br />Si 1 2-\ <br />Parameter/Standard Meets SJC Standards? Comments/Measurements Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (extends 2' from <br />casing) Yes No El NA El <br />Casing extends at least 12" above grade Yes No El NA El <br />Casing extends at least 1" above pedestal Yes No El NA Lii <br />Free of cracks/contiguous with annular seal Yes Di' No El NA El <br />Graded to allow drainage away from casing Yes VI No El NA El <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes da No El NA El <br />Seal between all pipe columns and casing Yes 01 No El NA El <br />Sounding tube/air vents sealed properly Yes14/ No El NA El <br />Chlorination port available and sealed properly Yes E' No El NA El <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 171 No El NA El <br />Adequately installed check valve or BFP device Yes VY No El NA El <br />Cross connections (ex: chemical feeders hooked <br />to distribution system/ag flood irrigation from <br />domestic supply) Yes El No IL ' NA El <br />Air gap of at least 6" (same as pipe diameter) Yes El No El NA pl <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes6 No NA El <br />Well/Pump free from excessive vegetation Yes No El NA El <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes No El <br />If no is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes No El <br />Photograph taken and attached to record Yes No El <br />OTHER: <br />Comments: <br />CkrA Tc-L v.-- \) (N \)14,_ 1 bes,.../.. q•-e-_ "c cr's2> <br />\ipdo c---r>v,c •.,-,4) __i._) s s=s3 _..- Cs-1 9--0- c-. e-- <br />Inspected By: Aaron Gooderham 0-„2 .06a2AQA14,7,—) 21 Title: Registered Environmental Health Specialist <br />Received By: Date: <br />EH-4200- 8/31/2015