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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: -0 Inspe �o%� of S S� wPa� tion Date: Parameter/Standard Meets SJC Standards? Com ments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes No ❑ NA ❑ Well is sealed between pump and casing Casingextends at least 12" above rade Yes No ❑ NA ❑ Seal between all pipe columns and casing Casing extends at least 1" above pedestal Yes No ❑ NA ❑ Sounding tube/air vents sealed properly Free of cracks/contiguous with annular seal Yes &J No ❑ NA ❑ Chlorination port available and sealed proper) Graded to allow drainage away from casing YesX No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: SANITARY SEAL: Well is sealed between pump and casing YesW No ❑ NA ❑ Seal between all pipe columns and casing Yes N, No ❑ NA ❑ Sounding tube/air vents sealed properly Yes tA No ❑ NA ❑ Chlorination port available and sealed proper) Yes ® No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head YesN 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 tR MAINTENANCE: Well/Pump visible and protected from damage Yes ® No ❑ NA ❑ Well/Pump free from excessive vegetation Yes La 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 R No ❑ OTHER: �p Comments: e I �2 U—�Gt•s �� (�i'Ye Inspected By: �� Title: ►\. g/1 S Received By: Date: I EH -4200- 8/31/2015