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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.sigov.orgiehd <br />PUMP INSPECTION CHECK LIST <br />Address: <br />till 1 LI j(i._ hS 1,,r&ti S-60c Kt-C), (17' Permit#: <br />o2 S6) wpo`1 <br />Insinqion gate: <br />' / Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes14 No NA LI <br />Casing extends at least 12" above grade Yesj5i1 No LI NA III <br />Casing extends at least 1" above pedestal Yes E No Liii NA LI <br />Free of cracks/contiguous with annular seal Yes J ] No LI NA LI <br />Graded to allow drainage away from casing Yes M No LII NA LI <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes N No LI NA LI <br />Seal between all pipe columns and casing Yes n No LI NA LIII <br />Sounding tube/air vents sealed properly Yes a No LI NA LI <br />Chlorination port available and sealed properly Yes K1 No NA Lii <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 11' No NA LI <br />Adequately installed check valve or BFP device Yes)71 No NA <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes LII No Nk,F1 <br />Air gap of at least 6" (same as pipe diameter) Yes-Igi No Il NA <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes,K No LII NA LI <br />Well/Pump free from excessive vegetation YJK No LI NA LI <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes L:j- No LI <br />If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes m- No <br />Photograph taken and attached to record Yes I I No,T1- <br />OTHER: <br />Comments: 7, - rJ c-'6-ou,,,,(alvd6P yea.) J -- <br />Inspected By: 721 SOtkCti ' Title: 5ic,,l1 WS <br />Received By: Date: <br />EH-4200- 8/31/2015