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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East HazeIton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.orgiehd PUMP INSPECTION CHECK LIST Address:— I-; (4 Inspection Date: Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes v No NA Casing extends at least 12" above grade Yes No NA Casing extends at least 1" above pedestal Yes E No LI NA LI Free of cracks/contiguous with annular seal Yes LI No 7 NA LI Graded to allow drainage away from casing Yes liii No Lii NA LI SANITARY SEAL: Well is sealed between pump and casing Yes n No LII NA LI Seal between all pipe columns and casing Yes LI No LI NA LI Sounding tube/air vents sealed properly Yes No LI NA LI Chlorination port available and sealed properly Yes LI No NA LI SAMPLE TAP AND BACKFLOW PREVENTION Non-threaded sample tap between well head and check valve or within 3' of well head Yes 11 No LI NA LI Adequately installed check valve or BFP device Yes LI No LI NA LI Any cross connections? (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes LI No LI NA ITT Air gap of at least 6" (same as pipe diameter) Yes No LII NA R MAINTENANCE: Well/Pump visible and protected from damage Yes El No LI NA LI Well/Pump free from excessive vegetation Yes III No LII NA LI MISCELLANEOUS: Permit drawing represents actual location of well Yes No LI If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes LI No LI Photograph taken and attached to record Yes IM No LI OTHER: Comments: Inspected By: \--/ii v. c r),,,i f' (c-c,..rc:„ 11_DA: i' i___ Title: Received By: Date: ,-') (I itoj, EH-4200- 8/31/2015