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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.sigov.org/ehd PIMP INSPECTION CHECK LIST Ad cess: P� STacr�, Permi W v o3-7/ 37 Insp do Date: C)//Q`.9//E Parameter/Standard Meets SJC Standards? Comments/Measurements! Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes V No ❑ NA ❑ Casing extends at least 12" above grade Yes [0 No ❑ NA ❑ Casing extends at least 1" above pedestal Yes [Z No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes K 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 IYes No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes CA No ❑ NA ❑ Adequately installed check valve or BFP device Yes VI 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 [A MAINTENANCE: Well/Pump visible and protected from damage Yes U No ❑ NA ❑ Well/Pump free from excessive vegetation Yes No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location• of well Yes U 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 No ❑ OTHER: Comments: Inspected By: t,U� S� Received By: Title: SSIS 1 Date: EH -4200- 8131/2015