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I <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sogov.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: rmit#: Inspection Date: <br /> L 6 S ova S c, Pewoo qj 4 7, <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal 2'x2'x4" minimum Yes E4 No ❑ NA ❑ <br /> Casing extends at least 12" above grade Yes TYf No ❑ NA ❑ <br /> Casing extends at least 1" above pedestal Yes No ❑ NA ❑ <br /> Free of cracks/contiguous with annular seal Yes No ❑ NA ❑ <br /> Graded to allow drainage away from casing Yes JA No ❑ NA ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Ye§�C No ❑ NA ❑ <br /> Seal between all pipe columns and casing Yes-] No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yes J0 No ❑ NA ❑ <br /> Chlorination port available and sealed properly Yes No ❑ NA ❑ <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 No ❑ NA ❑ <br /> Adequately installed check valve or BFP device Yes ❑ No NA ❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No ❑ NAS <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes Lji, No ❑ NA ❑ <br /> Well/Pump free from excessive vegeta ion Yes JA No ❑ NA ❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes No ❑ <br /> Permit drawing sufficient to locate well in future Yes No ❑ If'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER: <br /> Comments: /�/� I,, <br /> Ci <br /> / �IS�t V116c" �C K/ �r �N l� �1� -(-7'rTf <br /> I <br /> Inspected By: Title: <br /> Received By: Date: <br /> EH-4200- 8/31/2015 <br />