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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.orq/ehd PUMP INSPECTION CHECK L.I�T Address:4,55 W KEN Ell �, K �� 'G Q [, S Pei PO D 3 / s51 VCommcom/Measurernentsl l0 /V, 6 /� Parameter/Standard Meets SJC Standards? Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes JX 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 kA No ❑ NA ❑ Graded to allow drainage away from casing Yes No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes Q No ❑ NA ❑ Seal between all pipe columns and casing Yes [vim No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA 10 Chlorination port available and sealed properly Yes Q] 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 RA Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA MAINTENANCE: Well/Pump visible and protected from damage Yes V No ❑ lNo NA ❑ Well/Pump free from excessive vegetation Yes ® ❑ 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: 110 Title: — - - o4s�[J Received By: Date: Fu_n,nn_ 8/31/2015