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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: Al, ) eec, -W . c5fxK () y\ Permit#: Weboyl S' 2s Inspection Date: I 1z/ZO 2 Parameter/Standard Meets SJC Standards? CommentslMeas -- mentsr Recommendations CEMENT PEDESTAL: Dimensions of surface seal 2'x2'x4" minimum Yes §j No ❑ NA ❑ Casing extends at least 12" above grade Yes ®- No ❑ NA ❑ _ Casing extends at least V above pedestal Yes -E No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes ® No ❑ NA ❑ Graded. to allow drainage away from casing Yes P No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes Pj No ❑ NA ❑ Seal between all pipe columns and casing Yes No ❑ NA ❑ Sounding tube/air vents sealed properly Yes No ❑ NA ❑ Chlorination port available and sealed properly I 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'g Adequately installed check valve or BFP device YesXj No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes7N No ❑ NA ❑ Air gap of at least 6" (same as pipe diameter) Yes No ❑ NA ❑ MAINTENANCE: Well/Pump visible and protected from damage YesjR No ❑ NA ❑ Well/Pump free from excessive vegetation YesM No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes tA No ❑ If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yeses No ❑ Photograph taken and attached to record Yes ❑ Nola OTHER: _ Comments: � � _ JC Inspected By: J IJ Title: Received By: _ Date: EH -4200- 8/31/2015