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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.sogov.org/ehd PUMP INSPECTION CHECK LIST Address: } 1 Permit#: _ 1� Inspection Date: v,'�iL 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 0 No ❑ NA ❑ Casing extends at least 1" above pedestal Yes No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes M No ❑ NA ❑ Graded to allow drainage away from casing Yes CA No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes [A 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 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 Yes ® No ❑ NA ❑ Adequately installed check valve or BFP device Yes R No ❑ NA ❑ Any 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 E MAINTENANCE: Well/Pump visible and protected from damage Yes &I No ❑ NA ❑ Well/Pump free from excessive vegetation Yes X] 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: i A �, . Title: ` �� 5 moi, :7te Received By: ��' Date: 2 aZZ EH -4200- 8/31/2015