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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.sogov.org/ehd PUMP INSPECTION CHECK LIST Address: �7 ti• gy as Permit#: u�,Rv) y� G T I Inspection Date: cl -4 -2dy 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 ❑ Q WV Casing extends at least 1" above pedestal Yes V No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes [v]' No ❑ NA ❑ Graded to allow drainage away from casing Yes No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes [ No ❑ NA ❑ Seal between all pipe columns and casing Yes E� No ❑ NA ❑ Sounding tube/air vents sealed proper) Yes [yf No ❑ NA ❑ Chlorination port available and sealed properly Yes 21 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 INA ❑ Air gap of at least 6" (same as pipe diameter) IYes ❑ No ❑ 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 [� No ❑ if 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes [f No ❑ Photograph taken and attached to record Yes g No ❑ OTHER: Comments: A&A- e .«fir Le v.A- �•Pj1,jr 6jk S OAnQ_ wta '�' �' ur0 �sl' L cK "`] frd it �Ud .� d �/ •� �t..� , Inspected B &vr,.— "40 -eq..) Title: i- leee-,,els Received By: Date: EH -4200- 8/31/2015