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r 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: Permit#: 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 ElNA [:1Free of cracks/contiguous with annular seal Yes ❑ No ❑ NA [:1Graded to allow drainage away from casing Yes F1No F1NA ❑ 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 ❑ 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 I Yes ❑ INo ❑ NA ❑ Air gap of at least 6" (same as pipe diameter) I Yes ❑ No ❑ I 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 ❑ jNoE1 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: Inspected By: Title: Received By: Date: EH -4200- 8/31/2015