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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: 5311 N Jacktone Rd, Stockton Permit#: WP0042707 Inspection Date: 11/9/21 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 ❑ 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 ® lNo ❑ INA ❑ 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 3' of well head Yes ❑ No ❑ NA Adequately installed check valve or BFP device Yes ® No ❑ NA ❑ Any 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 ® No ❑ It'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: , Title: Received By: Date: ' t � 12 - EH -4200- EH -4200- 8/31 /2015