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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.sigov.org/ehd PUMP INSPECTION CHECK LIST Address- S 1f Permi Inspection Date: C �f �N0380 � v /l A: Parameter/Standard Meets SJC Standards? CommRecc mlMeasurements/ ommendations 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 V above pedestal Yes [' No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes M No ❑ NA ❑ Graded to allow drainage away from casing Yes Z No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes ❑d 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 [V SAMPLE TAP AND BACKFLOW PREVENTION: Non-threaded sample tap between well head and check valve or within 3' of well head Yes 0 No ❑ NA ❑ Adequately installed check valve or BFP device Yes P 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 MAINTENANCE: Well/Pump visible and protected from damage Yes © No ❑ NA ❑ Well/Pump free from excessive vegetation Yes ® No ❑ I NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes k2 No ❑ Permit drawing sufficient to locate well in future Yes U No ❑ if'no'is selected, attach an accurate map to permit Photograph taken and attached to record Yes E� No ❑ OTHER: Comments:/ Inspected By: CMS S Title: S S i•S Received By: Date: EH-4200- 8/31/2015