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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.slgov.orglehd PUMP INSPECTION CHECK LIST Address:� � � ��' � i �O � ^ C� Permit#• M 3 7 q 12 Insp ction Date: Parameter/Standard Meets SJC Standards? Comments/Measurements/Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes [Z 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 IYes No ❑ NA ❑ Graded to allow drainage away from casing Yes No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes 0 No ❑ NA ❑ _ Seal between all pipe columns and casing Yes W No ❑ NA ❑ Sounding tube/air vents sealed properly Yes F11 No ❑ NA ❑ Chlorination port available and sealed properly IYes ❑ No ❑ NA [j( 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 [0 MAINTENANCE: Well/Pump visible and protected from damage Yes EZ No 11 NA ❑ Well/Pump free from excessive vegetation Yes Y 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 No ❑ OTHER: Comments: Inspected By: Title: 1, - At% Received By: Date: FH..agnn_ 8/31/2015