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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.sogov.org/ehd PUMP INSPECTION CHECK LIST Address:Permit#: (,t✓ kc, � � �� Z Inspection Date: `1/Z-/ 2�' 2 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 ❑ 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 proper) Yes ❑ 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 ❑ No ❑ NA ❑ Adequately installed check valve or BFP device Yes ❑ 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 ❑ No ❑ NA ❑ Well/Pump free from excessive vegetation Yes ❑ No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes Er No ❑ If'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes NO ❑ Photograph taken and attached to record Yes ❑ No ° OTHER: Comments: I-�� Gtiu ow vw y re ecce 5s L AA ' S `q/P CEtli �C� Ll Y(�r'c�nipl +rte C;�Cc� ��UL"1 G' by2v k',t, 61c o , Inspected By: ) ��.� C�� (� �c=; ;, �_ ,pct Z Title: Received By: Date: X27 2 -CSL EH -4200- 8/31/2015