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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.slaov.org/ehd PUMP INSPECTION CHECK LIST Address: � o I. T Permit#: 1 �' 'Z�(I In ctio Date: 1 l o 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 Ye No ❑ NA ❑ Casing extends at least 1" above pedestal Yeses 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 -F7 No ❑ NA ❑ Chlorination port available and sealed properly Yeses 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-f�T Air gap of at least 6" same as pipe diameter) Yes ❑ No ❑ NAS' MAINTENANCE: Well/Pump visible and protected from damage Yes n No ❑ NA ❑ Well/Pump free from excessive vegetation Yes ❑ No NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Ye No ❑ if 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Ye o ❑ Photograph taken and attached to record Ye No ❑ OTHER: Comments: Inspected B C kL'% Title: Received By: A Date: { G v v — EH -4200- 8/31/2015