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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.sjoov.orgiehd <br />PUMP INSPECTION CHECK LIST <br />Address: <br />/40a). A/ V4fa, fi00.0-P, .544eA, <br />Permit#: <br />kift:o 1/24k <br />Inspection Date: <br />/6 -/y— 2/ <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes RI No / NA <br />Casing extends at least 12" above grade Yes No F1 NA <br />Casing extends at least 1" above pedestal Yes W7 No LII NA LI <br />Free of cracks/contiguous with annular seal Yes R/ No LI NA LI <br />Graded to allow drainage away from casing Yes R/ No Lii NA LI <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes 1211 No LI NA LI <br />Seal between all pipe columns and casing Yes F No LI NA LI, <br />Sounding tube/air vents sealed properly Yes No NA Illei <br />Chlorination port available and sealed properly Yes WI 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 Er No LI NA LI <br />Adequately installed check valve or BFP device Yes No LI NA LI <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes LI No LI NA <br />Air gap of at least 6" (same as pipe diameter) Yes LI No LI NA VI/ <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes PI No LI NA LI <br />Well/Pump free from excessive vegetation Yes W7 No LI NA LI <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes r4 No LI <br />If no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes igliNo <br />Yes 14 No LI Photograph taken and attached to record <br />OTHER: <br />Comments: <br />Inspected By: frikee---n----/I1-27 Title: 5r <br />Received By: Date: <br />EH-4200- 8/31/2015