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SAN JOAQUIN COUNTY ENVIRONMEN I AL HEAL I H DEPART MEN 1 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web:www.sagov.org/ehd PUMP INSPECTION CHECK LIST Address: % Permit#: Inspection Date: l'U o f j- S 7 k 2 c, Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal 2'x2'x4" minimum Yes No ❑ NA ❑ Casing extends at least 12" above grade Yes Ej No ❑ NA ❑ Casing extends at least 1" above pedestal Yes No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes ❑ 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 ❑ NA ❑ Chlorination port available and sealed properly Yes 0 No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non-threaded sample tap between well head and � check valve or within 3' of well head Yes 17 No ❑ NA ❑ Adequately installed check valve or BFP device Yes 5r No ❑ NA ❑ Any cross connections? (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes ❑ No INA Air gap of at least 6" (same as pipe diameter) jYes0 No ❑ NA MAINTENANCE: Well/Pump visible and protected from damage Yes ❑ No ❑ NA ❑ Well/Pump free from excessive ve etation Yes 0 No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes L o ❑ Permit drawing sufficient to locate well in future Yes t No ❑ If'no' is selected, attach an accurate map to permit Photograph taken and attached to record Yes El' No ❑ OTHER: Comments: 1 Inspected By: ('C ,Y L� Z Title: Received By: I Date: S Z EH-4200- 8/31/2015