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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.siqov orq/ehd <br />PUMP INSPECTION CHECK LIST <br />Address: 6/Li 50 <br />N "(474/— _ ("ct ) 54 6 C1(41 <br />Permi . „t#: <br />14,1660 <br />Inspection Date: <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes N No n NA <br />Casing extends at least 12" above grade Yes r% No LI NA Li <br />Casing extends at least 1" above pedestal Yes l'T-- No NA <br />Free of cracks/contiguous with annular seal Yes 51. No LII NA n <br />Graded to allow drainage away from casing Yes No Liii NA LI <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes 'II No I I NA LI <br />Seal between all pipe columns and casing Yes y No LI NA LII <br />Sounding tube/air vents sealed properly Yes I-7z No LIII NA LIII <br />Chlorination port available and sealed properly Yes 71 No LI NA LI <br />SAMPLE TAP AND BACKFLOVV PREVENTION. <br />Non-threaded sample tap between well head and <br />check valve or within 3' of well head Yes151 No LI NA I I <br />Adequately installed check valve or BFP device Yes M No LI NA Lii <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes 7 No LI NA151 <br />Air gap of at least 6" (same as pipe diameter) Yes LI No I I NA q.. <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes-- No LII NA 7 <br />Well/Pump free from excessive vegetation Yes `74- No LI NA <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes121-- No LI <br />If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes in No LI <br />Photograph taken and attached to record Yes 17- No <br />OTHER: <br />Cornments: <br />0 <br />0(% <br />Inspected By:1)0.1,-/c, rk-rijWci- 0___ Title: /12-- --r/S- <br />Received By: Date: -S/Z9/S4/ 2-/ <br />EH-4200- 8/31/2015