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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.or_q/ehd PUMP INSPECTION CHECK LIST Address: ��Zg ��'� �•'� : s�ocKt� �n Permit#: �,r%vYi �C; Ins ction Dat: L3n 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 [I NA ❑ Casing extends at least 1" above pedestal YesNo E]NA [:1Free of cracks/contiguous with annular seal YesN No ❑ NA ❑ e,KJA-4 410 Cit(ec4—S evA- Graded to allow drainage away from casing Yeses" No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing YesTK No ❑ NA ❑ Seal between all pipe columns and casing Yes No El NA El Sounding tube/air vents sealed properly Yes No ❑ NA ❑ Chlorination port available and sealed properl 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 El 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.k 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: CV0- -crL-5 o -v, p.e-dz5�r- do -v^ 1- e-rf cCt- t4e- s e-�.-( GZ , �0 , o ` - -to c1ti &-31 4"_1dA Inspected By: ! Title: Received By: Date: EH -4200- 8/31/2015