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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East HazeIton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.orq/ehd PUMP INSPECTION CHECK LIST Address: 8623 Carey Court, Stockton Permit#: WP0042369 Inspection Date: 10/29/21 Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes No NA Casing extends at least 12" above grade Yes I1 No NA Casing extends at least 1" above pedestal Yes I No Lii NA LI Free of cracks/contiguous with annular seal Yes I No LI NA LI Graded to allow drainage away from casing Yes 1 No NA SANITARY SEAL: Well is sealed between pump and casing Yes No NA LI Seal between all pipe columns and casing Yes X1 No NA Lii Sounding tube/air vents sealed properly Yes I No NA LI Chlorination port available and sealed properly Yes No Lii NA LI SAMPLE TAP AND BACKFLOW PREVENTION. Non-threaded sample tap between well head and check valve or within 3' of well head Yes No NA Lii Adequately installed check valve or BFP device Yes No LIII NA LI Any cross connections? (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes Lii No i1 NA LI Air gap of at least 6" (same as pipe diameter) Yes Lii No LI NA MAINTENANCE: Well/Pump visible and protected from damage Yes No LI NA LI Well/Pump free from excessive vegetation Yes No LIII NA LI MISCELLANEOUS: Permit drawing represents actual location of well Yes i1 No LII If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes ' No LI Photograph taken and attached to record Yes No LI OTHER: Cornments: Inspected By: Yt--t-z-k, Title: Received By: K Date: EH-4200- 8/31/2015