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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.sdgov.org/ehd PUMP INSPECTION CHECK LIST Address:Permits 003_70 Insp ction Date: 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 2No ElNA ❑ Casing extends at least 1" above pedestal Yes © No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes No ❑ INA ❑ Graded to allow drainage away from casing Yes ® No ❑ INAD SANITARY SEAL: Well is sealed between pump and casing Yes ® No ❑ INA ❑ 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 Q 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 [2 No ❑ NA ❑ A� SSP i`°�' `' No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) I Yes ❑No ❑ NA � Air gap of at least 6" (same as pipe diameter) Yes [7No ❑ NA ❑ MAINTENANCE: Well/Pump visible and protected from damage Yes [2 1 No ❑ NA ❑ Well/Pump free from excessive vegetation Yes U" I No ❑ INA ❑ 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 E, No ❑ Photograph taken and attached to record Yes © No ❑ OTHER: Comments: Inspected By: A , .� Ot fj Title: - I a �3 E, Received By: Date: EH -4200- 8/31/2015