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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.sjgov.orgiehd <br />PUMP INSPECTION CHECK LIST <br />Address: <br />6kbckq, \k,s....-\ i <L1(---vsz. <br />Permit#: <br />\Ari. bo,--k z- l -7 \ <br />Inspection Date: <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (extends 2' from <br />casing) Yes 125 No LI NA LI <br />Casing extends at least 12" above grade Yes No LI NA LI <br />Casing extends at least 1" above pedestal Yes No LI NA III <br />Free of cracks/contiguous with annular seal Yes No LI NA III <br />Graded to allow drainage away from casing Yes No LI NA LI <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes No Lii NA 1111 <br />Seal between all pipe columns and casing Yes No LI NA LI <br />Sounding tube/air vents sealed properly Yes Efl No Lii NA LI <br />Chlorination port available and sealed properly Yes LI No L NA d <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 Di No NA <br />Adequately installed check valve or BFP device Yes AI No NA LI <br />Cross connections (ex: chemical feeders hooked <br />to distribution system/ag flood irrigation from <br />domestic supply) <br />, <br />Yes 17f No N NA LII <br />Air gap of at least 6" (same as pipe diameter) Yes LI No LI NA 21 <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes No LI NA LI <br />Well/Pump free from excessive vegetation Yes ill No NA <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes 7 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 No LII <br />OTHER: <br />Comments: <br />_\c ' Q <br />, ,... LQ-/o'D c .),,N. •N• cs-c--c-'•c.ot-J (">•-•-.) f•ir'S-‘..XNAR),,,._ , <br /> <br />_ 1,),Ae.,•WC`D bsc___ Sc v..-t---9 <br />Inspected By: Aaron Gooderham Title: Registered Environmental Health Specialist <br />Received By: '1.A.ej- ..-1'..v•4-4..x-J Date: ki i "LI, './jl <br />EH-4200- 8/31/2015