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SAN JOAQUIN COUNTY ENVIRONMEN IAL HEAL-1 H DEPAR I MEN-1 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: I" Permi Inspection Date: 2 C l �Acc /1 1 el� i6r)0 v jS 1 Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal 21x2•x4" minimum Yes Mr, No ❑ NA ❑ Casing extends at least 12" above grade Yes No ❑ NA ❑ Casing extends at least 1" above pedestal Yes o ❑ NA ❑ Free of cracks/contiguous with annular seal Yes K6 No ❑ NA ❑ Graded to allow drainage away from casing Yes 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 El NA El 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 Q MAINTENANCE: Well/Pump visible and protected from damage Yes 0 1 No ❑ NA ❑ Well/Pump free from excessive vegetation Yes El I No ❑ INA ❑ MlSCF1 I.ANEOUS: 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 V❑ No ❑ OTHER: Comments: Inspected By: Title: S : �,q_ Received By: Date: G )PZG EH-4200- 8/31/2015