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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: rr (L: DGSL Permit#: , LV��— Inspectio Date: Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal 2'x2'x4" minimum Yes,0 No ❑ NA ❑ Casing extends at least 12" above grade YesE No ❑ NA ❑ Casing extends at least 1" above pedestal Yes -E] No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes --E] No ❑ NA ❑ Graded to allow drainage away from casing Yeses No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes ❑' No ❑ NA ❑ Seal between all pipe columns and casing Yes 0 No ❑ NA ❑ Sounding tube/air vents sealed properly Yesr❑ No ❑ NA ❑ Chlorination port available and sealed properly Yes -0 No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes Ej No ❑ NA ❑ Adequately installed check valve or BFP device Yes -E] No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes ❑ No ❑ NA Ll - Air gap of at least 6" same as pipe diameter) Yes ❑ No ❑ NA, MAINTENANCE: Well/Pump visible and protected from damage Yes-❑ No ❑ INA ❑ Well/Pump free from excessive vegetation Yes.E] No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes-❑ No ❑ It'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 Ej OTHER: Comments: i Inspected By: Title: Received By: Date: EH -4200- 8/31/2015