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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 PUMP INSPECTION CHECKLIST Address:r `? 1\j- PJ— F8 Permit#: �Po-0��-9 )3 Insp tiqn Date: 6O1Ir Parameter/Standard Meets SJC Standards? Com ments/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 0 No ❑ NA ❑ Graded to allow drainage away from casing Yes [VI 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 ❑ 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 Q' Air gap of at least 6" (same as pipe diameter) Yes ❑ No INA MAINTENANCE: Well/Pump visible and protected from damage Yes a No ❑ NA ❑ Well/Pump free from excessive vegetation Yes V 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:jis Received By: Date: FN_a?nn_ 8/31/2015