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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.sogov.org/ehd PUMP INSPECTION CHECK LIST Address:�(( 3_ _ r' T C� � Permit#: J / U 1 Insp'cti�� ate: Parameter/Standard Meets SJC Standards? Comments/Measurementst 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 V above pedestal Yes No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes No ❑ NA ❑ Graded to allow drainage away from casing Yes'N No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes JFj No ❑ NA ❑ Seal between all pipe columns and casing Yes T31; No ❑ NA ❑ Sounding tube/air vents sealed properly YesX No ❑ NA ❑ Chlorination port available and sealed properly YesjX 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 W 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 Yeses, No ❑ NA ❑ Well/Pump free from excessive vegetation Yes 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 o ❑ Photograph taken and attached to record Yes ❑ Noja OTHER: Comments: / C C efy of J fC J tG� �pG�l✓.J . Inspected By: Titled It -- Received By: Date: EH -4200- 8131/2015