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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 />4-40PQ' <br />Permit#: <br />b•--\ <br />Inspection Date: <br />(-)t ktea)t-.1 <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (extends 2' from <br />casing) Yesli No LII NA Ill <br />Casing extends at least 12" above grade Yes N\ No LI NA LI <br />Casing extends at least 1" above pedestal Yes4 No LI NA LI <br />Free of cracks/contiguous with annular seal Yes p No LI NA LI <br />Graded to allow drainage away from casing Yes q No LI NA LI <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes N,, No LI NA LI <br />Seal between all pipe columns and casing Yes lq No LI NA LI <br />Sounding tube/air vents sealed properly YesN1 No LI NA LI <br />Chlorination port available and sealed properly YesNR 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 <br />\_ <br />Yes IN No LI NA III <br />Adequately installed check valve or BFP device Yes1S No LI NA LI <br />Cross connections (ex: chemical feeders hooked <br />to distribution system/ag flood irrigation from <br />domestic supply) Yes LI No‘ENA LI <br />Air gap of at least 6" (same as pipe diameter) Yes LI No LI NANIR <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes sE\ No LI NA LI <br />Well/Pump free from excessive vegetation Yes"L, No LI NA LI <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes EcNo <br />YesRNo <br />Yes 1K\lo <br />LI <br />LI <br />If no is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future <br />Photograph taken and attached to record <br />OTHER: <br />• <br />Cornments: <br />1\1\\Co<L <br />t 0 <br />Inspected By: Aaron Gooderham 4 14 ea 44 . ,, % Title: Registered Environmental Health Specialist <br />Received By: 1.40 0 w....__ ,t ---3 &es-lc_ pv‘st—ic Nzci,, 5---e•Di,@...-LATARTAZE <br />EH-4200- 8/31/2015