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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fox: (209) 468-3433 Web: www.slgov.orq/ehd PUMP INSPECTION CHECK LIST Address: /, f U� ��j—b � J1 Vc ' i ori Permit#: SK007b q 9 Insp ctio Date: « . Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yesr No ❑ NA ❑ Casing extends at least 12" above grade Yes ® No ❑ NA ❑ Casing extends at least V above pedestal Yes ❑ No bg NA ❑ Free of cracks/contiguous with annular seal Ye No NA ❑ 11 Graded to allow drainage away from casing Yes J. No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes [' No ❑ NA ❑ Seal between all pipe columns and casing Yes © No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA [ Chlorination port available and sealed properly IYes • No ❑ NA ❑ SAMPLE TAP AND EACKI=LOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes LZ No ❑ NA ❑ Adequately installed check valve or BFP device Yes tA No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) IYes ❑ No ❑ NA K Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA MAINTENANCE: Well/Pump visible and protected from damage Yes 0 No ❑ NA ❑ Well/Pump free from excessive vegetation Yes Ui No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes Q No ❑ If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes U No ❑ Photograph taken and attached to record Yes No ❑ OTHER: Comments: ` tIAlt PP- , C. Q Cv-a, Inspected By: OLAA �J Title: /}fSN ��► Received By: Date: EH -4200- 8/31/2015