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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.org/ehd PUMP INSPECTION CHECK LIST Address; O� I L E T-1 L ( C� C,V- F n 1 Per i r O O3- F� I03e tion oq D/te: Parameter/Standard N Meets SJC StanddaJrds? r Comments/Measurement/s/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes E9 No ❑ NA ❑ Casing extends at least 12" above grade Yes [2 No ❑ NA ❑ Casing extends at least 1" above pedestal Yes U No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes ❑ No NA ❑ C r atA Graded to allow drainage away from casing IYes U No ❑ INA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes KI No ❑ NA ❑ Seal between all pipe columns and casing Yes [A No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NAI 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 Air gap of at least 6" (same as pipe diameter) IYes ❑ No ❑ NA MAINTENANCE: Well/Pump visible and protected from damage Yes No ❑ NA ❑ Well/Pump free from excessive vegetation Yes No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes No ❑ Permit drawing sufficient to locate well in future Yes © No ❑ If'no'is selected, attach an accurate map to permit Photograph taken and attached to record Yes No ❑ OTHER: Comments: C Lai Inspected By: a/c.\/ S Title: Received By: Date: EH-4200- 8/31/2015