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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: 3 s�� GLS I� - V-11,. Permit#: y()S IF Inspe ion Da e: ut/z l Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal 2'x2'x4" minimum) YesNt NO ❑ NA ❑ Casing extends at least 12" above grade Yes`®- No ❑ NA ❑ Casing extends at least 1" above pedestal Yes a No ❑ NA ❑ Free of cracks/contiguous with annular seal Yeses No ❑ NA ❑ Graded to allow drainage away from casing Yes No ❑ NA ❑ 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 R— No ❑ NA ❑ Chlorination port available and sealed properly Yes K No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yeses No ❑ NA ❑ Adequately installed check valve or BFP device Yesla No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes 1�3_ No ❑ NA ❑ Air gap of at least 6" (same as pipe diameter) Yes ' No ❑ NA ❑ MAINTENANCE: Well/Pump visible and protected from damage YesM No ❑ NA ❑ Well/Pump free from excessive vegetation Yes [a 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: / Title: 2> Received By: Date:,, Z EH -4200- 8/31/2015