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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.sjgov.org/ehd <br />PUMP INSPECTION CHECK LIST <br />lAddress: <br />..bk , i.A,fv(._ A,LA- S rvi.,14/1-Jete \ L <br />Permit#: <br />Lt/ rti -5 t 41- <br />Insppctiqn Date: <br />ck ( g( ia <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) YesZi. No LII NA LI <br />Casing extends at least 12" above grade Yesn No Eli NA LI <br />Casing extends at least 1" above pedestal Yes,r* No NA <br />Free of cracks/contiguous with annular seal Yeser No LI NA LI <br />Graded to allow drainage away from casing Yes fi No NA <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes-El No LIII NA LI <br />Seal between all pipe columns and casing YesE No LI NA LI <br />Sounding tube/air vents sealed properly Yes/r1 No NA LI <br />Chlorination port available and sealed properly Yesil No 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-I-1 No NA LI <br />Adequately installed check valve or BFP device Yes LI No LI NA LI <br />Any cross connections? (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) <br />..,- <br />Yes LI No LI NA n <br />Air gap of at least 6" (same as pipe diameter) Yes LII No LI NA ff. <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes-r1 No LI NA LI <br />Well/Pump free from excessive vegetation Yes IZ1 No LIII NA LI <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes,E1 No LI <br />If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes.0 No 1111111 <br />Photograph taken and attached to record Yes LI N941 <br />OTHER: <br />Comments: <br />Inspected By: <br />AC)2tjA <br />_ Title: <br />Received By: ' ' '( (--12C-014—'\ Date: 74-- ' —,,Z 2— <br />EH-4200- 8/31/2015