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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.swgov.org/ehd PUMP INSPECTION CHECK LIST Address: _?:Ml nh Permit#: Wpoa3� qUS Inspection Date: lis ll Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal 2'x2'x4" minimum Yes ❑ No NA ❑ Casing extends at least 12" above grade Yes ❑ No NA ❑ Casing extends at least 1" above pedestal Yes ❑ No NA ❑ Free of cracks/contiguous with annular seal Yes ❑ No NA ❑ Graded to allow drainage away from casing Yes ❑ 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 Yes N No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes No ❑ NA ❑ Adequately installed check valve or BFP device Yes No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes ❑ No ❑ NA Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA MAINTENANCE: Well/Pump visible and protected from damage Yes No ❑ NA ❑ Well/Pump free from excessive vegetation Yes No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes No ❑ if 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes No ❑ Photograph taken and attached to record Yes 2 No ❑ OTHER: Comments: c_ o,,,�,,,..-/- / /Vjn �ci LI r Cj-V Inspected By: vt l Title: �lct'h Received By: I Date: EH -4200- 8/31/2015