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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.slgov.org/ehd PUMP INSPECTION CHECK LIST Address: V,31 y I C 2/) Permit#: Inspection Date: Parameter/Stan and Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal 2'x2'x4" minimum Yes Ej. 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 M No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes No ❑ NA ❑ Seal between all pipe columns and casing Yes 29 No ❑ NA ❑ Sounding tube/air vents sealed properly Yes No ❑ NA ❑ Chlorination port available and sealed properl 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 Or No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes a No ❑ NA ❑ Air gap of at least 6" (same as pipe diameter) Yes la No ❑ NA ❑ MAINTENANCE: Well/Pump visible and protected from damage Yes .5 No ❑ NA ❑ Well/Pump free from excessive vegetation Yes—n No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes J�j 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: 1r -e Sc7c- Inspected By: �YC Title: Received By: �— Date: 2 r? S z Z EH -4200- 8/31/2015