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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 CHECK LIST Address: �1 Permit#: Inspection Date: MN Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes [a No ❑ NA ❑ Casing extends at least 12" above grade Yes E' No ❑ NA ❑ Casing extends at least 1" above pedestal Yes 9 No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes [a No ❑ NA ❑ Graded to allow drainage away from casing Yes [Z' No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes [j No ❑ NA ❑ Seal between all pipe columns and casing Yes El No ❑ NA ❑ Sounding tube/air vents sealed proper) Yes ❑ No ❑ NA 0 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 ❑' Any 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 ❑" 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 Z No ❑ Permit drawing sufficient to locate well in future Yes [:3/ No ❑ If ono'is selected, attach an accurate map to permit Photograph taken and attached to record Yes No ❑ OTHER: Comments: Inc.�;mP1e�-e �u►Y,� �-�p�u��mens Inspected B : Title: Received By: Date: EH-4200- 8/31/2015