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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 tax: (209) 468-3433 Web: vwvw.sigov.org/ehd RUMP INSPECTION CHECK LIST Address: C, n n � Ck� I U PMe-os� O q Insp tion O S I b V ! Date; Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes [7 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 [A No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes ® No ❑ INA ❑ Seal between all pipe columns and casing Yes Q No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ® No ❑ NA ❑ Chlorination port available and sealed properly lYes ❑ 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 2 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) lYes ❑ No INA Air gap of at least 6" (same as pipe diameter) I Yes ❑ No ❑ INA [Z MAINTENANCE: Well/Pump visible and protected from damage YesE2 No ❑ NA ❑ Well/Pump free from excessive vegetation Yes No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes D 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: CL, Title: F Aq < Received By: Date: EH -4200- 8/31/2015