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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.s4gov.org/ehd PUMP INSPECTION CHECK LIST Address: ` /, /� 1 (� vSV � 01-" 1*- "Je '711. �1�� 6. (/ [ , ,, Permit#: /( -7 Lti E'.JTI /7 Inns�pection Date: 1�1fI12/ Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes L 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 Yes No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes [ 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 21, 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 ❑ Any 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 Lj' No ❑ NA ❑ Well/Pump free from excessive vegetation Yes [J' 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 B 1 t Title: ^jP_ - Received By: Date: EH -4200- 8/31/2015