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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: �'J � 2 E. Co �� c� l is St-ocKtoin Per it#: 00 y Z 70q Inspection Date: _ Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum Yes JR_ No ❑ NA ❑ Casing extends at least 12" above grade Yes No ❑ NA ❑ Casing extends at least 1" above pedestal Yes No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes No ❑ NA ❑ Graded to allow drainage away from casing YesEf lNo ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes la No ❑ NA ❑ Seal between all pipe columns and casing Yes 9 No ❑ NA ❑ Sounding tube/air vents sealed properly Yes � No ❑ NA ❑ Chlorination port available and sealed proper) 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''. 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 ❑ N Air gap of at least 6" (same as pipe diameter) Yes No ❑ NA ❑ MAINTENANCE: Well/Pump visible and protected from damage Yes, No E] NA ❑ Well/Pump free from excessive vegetation Yes No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes Fj No ❑ if 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yesa No ❑ Photograph taken and attached to record Yes ❑ No OTHER: Comments: Inspected By: " ,5��,� Title: '5 J Received By: Date: EH -4200- 8/31/2015