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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.orgiehd <br />PUMP INSPECTION CHECK LIST <br />Address: <br />t°0;:b12\ \TC 4:N. L.-r "(4 1C''' <br />Permit: <br />\k \ tcb-S <br />Inspection Date: 3 ji-z. 1-2.crIA <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (extends 2' from <br />casing) YesP1S\ No LI NA LI <br />Casing extends at least 12" above grade Yes N\, No LI NA LI <br />Casing extends at least 1" above pedestal Yes No Lii NA LI <br />Free of cracks/contiguous with annular seal Yes No NA LI <br />Graded to allow drainage away from casing YesiScNo LI NA Lii <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes' No NA LI <br />Seal between all pipe columns and casing Yes No LI NA LI <br />Sounding tube/air vents sealed properly Yes.IS No LI NA Lii <br />Chlorination port available and sealed properly Yes a 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'IS No LI NA LI <br />Adequately installed check valve or BFP device Yes'I No 1111111 NA LI <br />to distribution system/ag flood irrigation from <br />domestic supply) <br />Cross connections (ex: chemical feeders hooked <br />Pb4,5kfc. <br />YesIL, No LI NA LI <br />Air gap of at least 6" (same as pipe diameter) Yes LI No LI NANISIN <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes1 No LI NA LI <br />Well/Pump free from excessive vegetation Yes '1S1 No LI NA LI <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes No LI <br />It 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes" N No LI <br />Photograph taken and attached to record Yes icl, No LI <br />OTHER: <br />Comments: <br />Inspected By: Aaron Gooderham c......cf5rN P'yaLat14;),,,te, Title: Registered Environmental Health Specialist <br />Received By: V110 (s..k,3 fc.,. oN.Ds•c_Ic „..- Date: <br />EH-4200- 8/31/2015