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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.slgov.org/ehd PUMP INSPECTION CHECK LIST Address: I(,, - 9 -ADI Permit#: Inspedo Q Date: Z Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: 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 V above pedestal Yes ❑ No NA ❑ Free of cracks/contiguous with annular seal Yes ❑ 1 No �NA NA El Graded to allow drainage away from casingYes ❑ No ❑ 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 X 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 [71 NA Air gap of at least 6" same as pipe diameter Yes ❑ No ❑ NA It MAINTENANCE: Well/Pump visible and protected from dama e Yes No ❑ NA ❑ Well/Pump free from excessive vegetation Yes No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes E6 No ❑ 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: Aaron Gooderha - Title: Registered Environmental Health Specialist Received By: Date: v� EH -4200- 8/31/2015