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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.s'gov.org/ehd PUMP INSPECTION CHECK LIST Address: /� (()) Q� 1 Ol !El � LrL►�rC! CA- TJ Z4� Parameter/Standard Meets SJC Standards? Permit#: p (U �G� J h � Inspection Date: Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal 2'x2'x4" minimum Yes 0 No ❑ NA ❑ Casing extends at least 12" above grade Yes [ No ❑ NA ❑ Casing extends at least 1" above pedestal Yes 0 No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes Z 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 [Z' No ❑ NA ❑ Sounding tube/air vents sealed properly Yes No ❑ NA ❑ Chlorination port available and sealed proper) 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 e 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 J7 Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA [✓" MAINTENANCE: Well/Pump visible and protected from damage Yes [V No ❑ NA ❑ Well/Pump free from excessive vegetation Yes Vr No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes 0 No ❑ If'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes u No ❑ Photograph taken and attached to record Yes [+T No ❑ OTHER: Comments: Inspected By: Title: r� 1 Received By: I Date: *-",'j V EH -4200- 8/31/2015