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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.orq/ehd PUMP INSPECTION CHECK LIST P:cidress: T _ SI�0 Permit4; 0030. 52�A Inspection Date: /3J ( Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes I No ❑ NA ❑ Casing extends at least 12" above grade Yes No ❑ NA ❑ Casing extends at least T' above pedestal Yes No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes ❑ No K] NA F-1tNoj Graded to allow drainage away from casing Yes ❑ No NA ❑ 0 o C SANITARY SEAL: Well is sealed between pump and casing Yes INo ❑ INA ❑ 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 d No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within T of wellhead j Yes d No ❑ �NA ❑ Adequately installed check valve or BFP device Yes [I No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes ❑ No NA El Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA MA.INTENA:NCE: 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 ❑ li 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in futureYes No ❑ Photograph taken and attached to record IYes No ❑ OTHER: Comments: 1 Inspected By: Title: e. Received By: Date: