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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: vvww.sigov.orgiehd <br />PUMP INSPECTION CHECK LIST <br />Address: <br />NtS •.) PA,-) $E><\/.." j .`z=.C.--t>cL—Co /4 <br />Permitl: <br />\A) ? DO 4 tiLt3 <br />Inspection Date: <br />W/Aft-i <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (extends 2' from <br />casing) Yes 21 No LI NA LI <br />Casing extends at least 12" above grade Yes VI No LI NA LI <br />Casing extends at least 1" above pedestal Yes III No LI NA LI <br />Free of cracks/contiguous with annular seal Yes 12i No LI NA LI <br />Graded to allow drainage away from casing Yes El No NA LI <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes No Liii NA LI <br />Seal between all pipe columns and casing Yes No LI NA LI <br />Sounding tube/air vents sealed properly Yes No LI NA LI <br />Chlorination port available and sealed properly Yes 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 LIz No LI <br />, <br />NA <br />Adequately installed check valve or BFP device Yes 1311 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 Ei NA q <br />Air gap of at least 6" (same as pipe diameter) Yes No LI NA Oil <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes No LI NA LI <br />Well/Pump free from excessive vegetation Yes No 111111 NA LI <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes No LI <br />If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes No <br />Photograph taken and attached to record Yes [71 No LI <br />OTHER: <br />Comments: k . — <br />\AQ —11 • 1—ari 0\ • e ck,V1 @Y1C1A • COWI ' <br />2 ' _ Title: Registered Environmental Health Specialist Inspected con Goo dir(r.„} <br />Received : :. ,..VAAACe „4,fLezes, Date: /.,9 ( <br />EH-4200- 8/31/2015