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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.or /q ehd PUMP INSPECTION CHECK LIST Address: i b 5 o& vt � a �� i -o h Permit#: J Inspction ate: ` i 3 �1 Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes ❑ No NA ❑ 3}► �,,,.yE,r,,; Hca, Casing extends at least 12" above grade Yes ❑ Noo NA ❑ N Casing extends at least V above pedestal Yes L] No ❑ NA ❑ Free of cracks/contiguous with annular seal YesZ No ❑ NA ❑ Graded to allow drainage away from casing YesZ No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes2 No ❑ NA ❑ Seal between all pipe columns and casing Yeso No ❑ NA ❑ Sounding tube/air vents sealed properly YesE] No ❑ NA ❑ Chlorination port available and sealed properly Yes.O 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 YesET No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) YeslK jNo ❑ NA Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA MAINTENANCE: Well/Pump visible and protected from damage Yeses No ❑ NA ❑ Well/Pump free from excessive vegetation Yes�Ll No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes o ❑ If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Ye ❑ Photograph taken and attached to record YesK No ❑ OTHER: Comments: Inspected By: U,- V (✓L b "312 1�' \ Title: Cj L'. f e Received By: Date - L- 9 1 L9l SeNLo'4 C k? AI /-. CzPAl EH -4200- EH-4200- 8/31 /2015