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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.org/ehd PUMP INSPECTION CHECK LIST Address: llIns 31) ,U v�r�- GCS- `'yv, � �r,. .ti Permit#: I ection 9ate: 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 YesDd No ❑ NA ❑ Graded to allow drainage away from casing Yes M No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes Kj No ❑ NA ❑ Seal between all pipe columns and casing Yes W No ❑ NA ❑ Sounding tube/air vents sealed properly Yes IN No ❑ NA ❑ Chlorination port available and sealed properly Yes Eg 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 N No ❑ NA ❑ Air gap of at least 6" (same as pipe diameter) YesN No ❑ NA ❑ MAINTENANCE: Well/Pump visible and protected from damage Yes R No ❑ NA ❑ Well/Pump free from excessive vegetation Yes N 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 0 No ❑ Photograph taken and attached to record Yes S No ❑ OTHER: Comments: l%et Inspected By: IZA41) G(L Title: Received By: I Date: Z Zi Z EH -4200- 8131/2015