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OTHER: <br />Comments: <br />nspectedBy:Vo-A4 Nj .'U Title: 1/crDh lsw► --f oe-(t 4fJ�, <br />Zeceived By: Date: <br />cu n)nn <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web; www.sigov.oralehd <br />PUMP INSPECTION LIST <br />/CHECK <br />Addre�sO 1. 6C. 6E �.�� 5T t) c % b f�! pW O03-7-208 Insp or <br />11 ))�� n <br />C- <br />/0 �D G <br />Parameter/Standard <br />Meets SJC Standards? CommentslMeasurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) <br />Yes 5� No ❑ NA ❑ <br />Casing extends at least 12" above grade <br />Yes V No ❑ NA ❑ <br />Casing extends at least 1" above pedestal <br />Yes No ❑ NA ❑ <br />Free of cracks/contiguous with annular seal <br />Yes V No ❑ NA ❑ <br />Graded to allow drainage away from casing <br />Yes M No ❑ NA ❑ <br />SANITARY SEAL: <br />Well is sealed between pump and casing <br />Yes No ❑ NA El <br />Seal between all pipe columns and casing <br />Yes VI No ❑ NA ❑ <br />Sounding tube/air vents sealed properly <br />Yes ❑ No ❑ NA <br />Chlorination port available and sealed properlyYes <br />:_V JNo ❑ INA ❑ <br />SAMPLE TAP AND BACKFLOW PREVENTION: <br />Non -threaded sample tap between well head and <br />check valve or within 3' of well head <br />Yes V No ❑ NA ❑ <br />Adequately installed check valve or BFP device <br />Yes No ❑ NA ❑ <br />No cross connections (ex: chemical feeders <br />[from <br />ooked to distribution system/ag flood irrigation <br />domestic supply) <br />Yes ❑ No ❑ NAM <br />Air gap of at least 6" (same as pipe diameter) <br />Yes ❑ No ❑ NA FiA <br />MAINTENANCE: <br />Well/Pump visible and protected from damage <br />Yes No ❑ <br />NA ❑ <br />Wel(/Pump free from excessive vegetationYes <br />No F-1 <br />NA ❑ <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well <br />Yes No ❑ <br />Permit drawing sufficient to locate well in future <br />Yes [� No ❑ If 'no' is selected, attach an accurate map to permit <br />Photograph taken and attached to record <br />Yes ® No ❑ <br />OTHER: <br />Comments: <br />nspectedBy:Vo-A4 Nj .'U Title: 1/crDh lsw► --f oe-(t 4fJ�, <br />Zeceived By: Date: <br />cu n)nn <br />