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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.sjgov.orq/ehd PUMP INSPECTION CHECK LIST Address: � O Permit#: Parameter/Standard�j I Meets SJC Standards? Crommments/Measurem/e Recommendations n CEMENT PEDESTAL: Dimensions of surface seal 2'x2'x4" minimum Yeses] No ❑ NA ❑ Casing extends at least 12" above grade Yes No ❑ NA ❑ Casing extends at least 1" above pedestal YeSK] No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes 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 E] No ❑ NA ❑ Chlorination port available and sealed properly lYesaNo ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes Vj No ❑ 'NA ❑ Adequately installed check valve or BFP device Yes ,J�t No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yeses No ❑ NA ❑ Air gap of at least 6" (same as pipe diameter) Yeses No ❑ NA ❑ MAINTENANCE: Well/Pump visible and protected from damage Yes [�J- No ❑ NA ❑ Well/Pump free from excessive vegetation Yes fa 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: yy /�� rio(� // eetS &/1 SYc �S'-&Lr1 Inspected By: / r , l�f✓ Il.( I Title: G YJ Received By: Date: l EH -4200- 8/31/2015