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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.sagov.org/ehd PUMP INSPECTION CHECK LIST Address: ' CI'-- Permit#: w r' IL 44 Inspection Date: ,k (z Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal 2'x2'x4" minimum Yes [ET . No ❑ NA ❑ Casing extends at least 12" above grade Yes el No ❑ NA ❑ Casing extends at least 1" above pedestal Yeses No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes No ❑ NA ❑ Graded to allow drainage away from casing Yes E�j No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes ©"' No ❑ NA ❑ Seal between all pipe columns and casing Yesn No ❑ NA ❑ Sounding tube/air vents sealed proper) Yeses No ❑ NA ❑ Chlorination port available and sealed properly Ye No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes [I 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) Yesi7f No ❑ NA ❑ Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA El MAINTENANCE: Well/Pump visible and protected from damage Yes No ❑ NA ❑ Well/Pump free from excessive vegetation Yes 2' No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yesr 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 F1 No ❑ OTHER: Comments: Ck Inspected By: �i (,l 3 �' Title: Received By Date: 12? `Z ,Z� .., EH -4200- 8/31/2015