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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 Address: w\\ C_ P1_. Permit#: �-kvZ Inspection Date: to IZ6�21 Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: c Dimensions of surface seal (extends 2' from casing) 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 ❑ 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 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 T of well head Yes No ❑ NA ❑ Adequately installed check valve or BFP device Yes No ❑ NA ❑ 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 Yes No ❑ NA ❑ Well/Pump free from excessive vegetation Yes No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes V,.No ❑ If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes o ❑ Photograph taken and attached to record Yes No ❑ OTHER: Comments: Inspected By: Aaron Gooderham Title: Registered Environmental Health Specialist Received By: I Date: EH -4200- 8/31/2015