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Parameter/Standard Meets SJC Standards? Yes Non-threaded sample tap between well head and check valve or within 3' of well head Yes No If 'no' is selected, attach an accurate map to permit Yes Permit drawing sufficient to locate well in future No El MISCELLANEOUS: Permit drawing represents actual location of well EH-4200- 8/31/2015 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East HazeIton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.orq/ehd PUMP INSPECTION CHECK LIST Address: `Q1 \ i-AN) N--Ss'(‘' I \f's Inspection Date: 3 Comments/Measurements/ Recommendations PermitGlt: CEMENT PEDESTAL: Dimensions of surface seal (extends 2' from casing) Casing extends at least 12" above grade Casing extends at least 1" above pedestal Free of cracks/contiguous with annular seal Graded to allow drainage away from casing Yes / Yes No D NA CI No LI NA El Yes No El NA D Yes Yes No El NoEl NALI NALI SANITARY SEAL: Well is sealed between pump and casing Seal between all pipe columns and casing Sounding tube/air vents sealed properly Chlorination port available and sealed properly Yes [21' Yes DI Yes g Yes NoEl NoEl No D NoEl NA El NA D NAIl NAIl SAMPLE TAP AND BACKFLOW PREVENTION No 111 NA El Adequately installed check valve or BFP device Cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Air gap of at least 6" (same as pipe diameter) MAINTENANCE: Yes No LI NA 111 Yes El Yes 111 No NoEl NA up NA 71 Well/Pump visible and protected from damage Yes No 111 NA 111 Well/Pump free from excessive vegetation Yes No 111 NAIl Photograph taken and attached to record OTHER: Yes No 111 Title: Registered Environmental Health Specialist Date:5-19 -2,1 Inspected By: A Gooderham a..%<301\ eVt1124, • .Aff-ei" ell't Received B