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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.sj oq v.org/ehd PUMP INSPECTION CHECK LIST Address:K/!� �,� C id til' ��' P�zr vii q Z'C ZZ In2p� � Dade: 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 No ❑ NA ❑ Casing extends at least 1" above pedestal Yes l No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes El No ❑ NA ❑ Graded to allow drainage away from casing Yes'® No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing YesE 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 E No ❑ NA ❑ Adequately installed check valve or BFP device Yes &J 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) Yes No ❑ INA ❑ 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 `nog is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes [I No ❑ Photograph taken and attached to record Yes ❑ No OTHER: Comments: Inspected By:�El'Title: Received By: �- Date: EH -4200- 8/31/2015