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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: ltU. 2 «Y ��le V��I..� C� Ci Permit#: V Inspection Date: 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 ❑ NoNA E]Graded to allow drainage awayfrom casingYes El 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 properly Yes No ❑ NA ❑ Chlorination port available and sealed properly Yes EZ No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes [Zf 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 E" Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA LZ 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 No ❑ if 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes 7. No ❑ Photograph taken and attached to record Yes ff No ❑ OTHER: Comments: Inspected By: ! c�t� t Title: Received By: Date: a) EH -4200- 8/31/2015