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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: ��c.ck�', (J �l C(P�'�C..� 13 ,r `� S 2Z 7 Parameter/Standard Meets SJC Standards? Permit#: (� P�o�l� l Inspection Date: LlI z7�z�'Fl Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes � No ❑ NA ❑ Casing extends at least 12" above grade Yes [D' 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 ff 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 ❑ NA Adequately installed check valve or BFP device Yes 0' No ❑ NA ❑ Any cross connections? (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes d No ❑ NA ❑ Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA [v' MAINTENANCE: Well/Pump visible and protected from damage Yes Ej No ❑ NA ❑ Well/Pump free from excessive vegetation Yes LZ' No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes EONo ❑ 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 D No ❑ OTHER: Comments: Inspected B �1 P y: �� %ly�lc_ Title: - Received By: Date: —z - EH -4200- 8/31/2015