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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.siclov.org/ehd PUMP INSPECTION CHECK LIST Address: CoIJrj� C- �C- .��c�� Perm' c„ oo393 Inspec o ate: o6 fiF Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes C7 No ❑ NA ❑ Casing extends at least 12" above grade Yes 0 No ❑ NA ❑ Casing extends at least 1" above pedestal Yes [A No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes A No ❑ NA ❑ Graded to allow drainage away from casing [2 No ❑ NA ❑ -Yes SANITARY SEAL: Well is sealed between pump and casing Yes [a" No ❑ NA ❑ Seal between all pipe columns and casing Yes ❑✓ No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA [R 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 [�2 No ❑ NA ❑ Adequately installed check valve or BFP device Yes [V' 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 Z 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 No ❑ Photograph taken and attached to record Yes No ❑ OTHER: Comments: Inspected By: Title: 4, els 2J Received By: Date: EH -4200- 8/31/2015