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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.si_qoLorq/ehd PUMP INSPECTION CHECK LIST Address:/ ?I X, Li/ 1 E?r C,j Permi • � 7/� ;7,,>� 50 / Inspection ate: 111 Parameter/Standard Meets SJC Standards? comments/Measurem nts Recommendations CEMENT PEDESTAL: Dimensions of surface seal 2'x2'x4" minimum Yes/❑ No NA ❑ r-' - Casing extends at least 12" above grade Yes 0 No ❑ NA ❑ Casing extends at least 1" above pedestal Yes ❑ No ❑ NA P Free of cracks/contiguous with annular seal Yes ❑ 1 No ❑ NA Graded to allow drainage away from casing Yes ❑ INoD INA SANITARY SEAL: Well is sealed between pump and casing Yes E] 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 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 4�j NA ❑ : x Adequately installed check valve or BFP device Yes a 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 ❑ NA [R MAINTENANCE: Well/Pump visible and protected from damage Yes No ❑ NA ❑ Well/Pump free from excessive vegetation Yes 0- No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes [R 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 f� No ❑ OTHER: Comments: c. �- -4- Inspected By: Title: .1111 Received By: Date: EH -4200- 8131/2015