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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'qov.org/ehd PUMP INSPECTION CHECK LIST Address: - Ss 9-41 EH-4200- Permi L-1 l Inspection Date: 5196121 Parameter/ tandard 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 [5f No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes �4 No ❑ NA ❑ Graded to allow drainage away from casing Yes No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes Y No ❑ NA ❑ Seal between all pipe columns and casing Yes[A No ❑ NA ❑ Sounding tube/air vents sealed properly Yes 171 No ❑ NA ❑ Chlorination port available and sealed properly Yes t2 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 ❑ No 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 YesK 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 No ❑ Photograph taken and attached to record Yes No ❑ OTHER: Comments: PC's S Inspected By: C�"_ Title: Received By: 2 Date: S1,2— EH-4200- 8/31/2015