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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/eh PUMP INSPECTION CHECK LIST Address: O �, f M Perm P0o3816 q Inspection Pate: 10442c,/8 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 No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes 0 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 V Air gap of at least 6" (same as pipe diameter) Yes ❑ jNoE1 INA MAINTENANCE: Well/Pump visible and protected from damage Yes 0 1 No ❑ NA ❑ Well/Pump free from excessive vegetation I Yes FA No ❑ INA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes INo ❑ If'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes Q No ❑ Photograph taken and attached to record Yes V No ❑ OTHER: Comments: Inspected By: aAl, Title: E - H ASS (3 Received By: Date: EH -4200- 8131/2015