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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: l U M, �® `� � I2 z 1"I� ll� ��t�� Permit#: �,��,�,u r ss� Ins ctio Date: �i� zz_ Parameter/Standard Meets SJC Standards? Comments/Measurements/'Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) No ❑ NA ❑ Casing extends at least 12" above grade Yes ED No ❑ NA ❑ Casing extends at least 1" above pedestal Yes ® No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes E] No ❑ NA ❑ Graded to allow drainage away from casing Yes E] 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 El No ❑ NA ❑ Chlorination port available and sealed properly 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 Yeses No ❑ NA ❑ No 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) I Yes ❑] No ❑ NA ❑ MAINTENANCE: Well/Pump visible and protected from damage Yes No ❑ NA ❑ Well/Pump free from excessive vegetation Yes ❑ 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 0 No ❑ Photograph taken and attached to record Yes ❑ No,1'3 OTHER: Comments: Inspected By: � S � ' C � ( Title: s�. Received By: �— Date: EH -4200- 8/31/2015