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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: � � f D Ar` � /,,, d. Permit#: Inspection Date' Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal 2'x2'x4" minimum Yes [f No ❑ NA ❑ Casing extends at least 12" above grade Yes f'T No ❑ NA ❑ Casing extends at least 1" above pedestal Yes] No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes�M No ❑ NA ❑ Graded. to allow drainage away from casing Yes No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes S1 No ❑ NA ❑ Seal between all pipe columns and casing Yes Fxj No ❑ NA ❑ Sounding tube/air vents sealed properly Yes a 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 ❑ No 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 F�F' 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 No ❑ Photograph taken and attached to record Yes No ❑ OTHER: Comments: Inspected By: / G Title: c/ r'J Received By: Date: t. EH -4200- 8/31/2015