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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: �; Permit#: Inspection Date: �7S `I S TO �, i ► S`�-tk �i ., 4� 71 Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes E] No ❑ NA ❑ Casing extends at least 12" above grade Yes a 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 v No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes a No ❑ NA ❑ Seal between all pipe columns and casing Yes Er No ❑ NA ❑ Sounding tube/air vents sealed properly Yes Ej No ❑ NA ❑ Chlorination port available and sealed properly Yes a No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non-threaded sample tap between well head and check valve or within 3' of well head Yes El' No ❑ NA ❑ Adequately installed check valve or BFP device Yes 0' No ❑ NA ❑ Any cross connections? (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes ❑ No ❑ NA 0' Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA jr MAINTENANCE: Well/Pump visible and protected from damage Yes No ❑ NA ❑ Well/Pump free from excessive vegetation Yes El No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes [Z] 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 0 No ❑ OTHER: Comments: Inspected By: V c,.1S Title: A.j Received By: Date: EH-4200- 8/31/2015