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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. siclov . org/ehd PUMP INSPECTION CHECK LIST Address : rr n Permit#: Inspection Date : Parameter/Standard Meets SJC Standards ? Comments/Measurements/ Recommendations CEMENT PEDESTAL : Dimensions of surface seal (2 ' x2 ' x4 " minimum ) Yes Er No ❑ NA ❑ Casing extends at least 12 above grade Yes r No ❑ NA ❑ Casing extends at least 1 " above pedestal Yes No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes [Eri 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 [j No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ff; No ❑ NA ❑ 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 [fi No ❑ NA ❑ Adequately installed check valve or BFP device Yes 00� 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 Z� No ❑ NA ❑ Well/Pump free from excessive vegetation Yes 0**� No ❑ NA ❑ MISCELLANEOUS : Permit drawing represents actual location of well Yes Rr 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 No ❑ OTHER : Comments : Inspected By : f� �a ,1 i _a Title : t /� t 7/ Received By : Date : Z � v z / EH -4200- 8/31 /2015