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SAN aJOAQUIN 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 INSPECOTION CHECK LIST Address: � 1�� ll aZz EH-4200- Permit#: Inspection Date: 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 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 S 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 YesFK11 No ❑ NA ❑ Chlorination port available and sealed proper) 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 V1 No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes ❑ No ❑ NA 0 Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA Q 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'nois 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: /-. :3 ,'�L V 12Z - Title: Received By: 2 Date: 1'2- EH-4200- 8/31/2015