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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.orglehd <br />PUMP INSPECTION CHECK LIST <br />Address: Perini • Insp ction Date: <br />�� Lm a hJ vJ 00 WV O a 3 6 /22 <br />Parameterlstandard Meets SJC Standards? Commenfis/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes ❑ No ❑ NA ❑ <br />Casina extends At fPASt 19- ahmm ri,,4V-- r -i I PIT- M I KIA r—i I I <br />Casing extends at least V above pedestal <br />I IN 20_LIj NA I14 <br />No ❑ <br />NA ❑ <br />A <br />Free of cracks/contiguous with annular seal <br />§Yes* <br />No © <br />NA ❑ <br />W <br />Graded to allow drainage away from casing <br />No ❑ NA©' <br />No ❑ <br />NA ❑ <br />Well/Pump visible and protected from damageYes <br />SANITARY SEAL: <br />free from excessive vegetation Yes ❑/"NA <br />MNoF-1❑ <br />MISCELLANEOUS: <br />Well is sealed between pump and casing <br />Yes <br />No ❑ <br />NA ❑ <br />Seal between all pipe columns and casing <br />Yes W1 <br />No ❑ <br />NA ❑ <br />.,..y uuoi au vci ua ocanmu Nl upr;1 ly Y eS LI <br />I IN 20_LIj NA I14 <br />Chlorination port available and sealed properly IYes <br />No ❑ NA ❑ <br />SAMPLE TAP AND BACKFLOW PREVENTION: <br />Non -threaded sample tap between well head and <br />check valve or within 3' of well head Yes <br />No ❑ NA ❑ <br />Adequately installed check valve or BFP device Yes <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes ❑ <br />No ❑ NA ❑ <br />No ❑ NA [V <br />Air gap of at least 6" (same as pipe diameter) Yes ❑ <br />No ❑ NA©' <br />MAINTENANCE: <br />Well/Pump visible and protected from damageYes <br />NA [:1Well/Pump <br />free from excessive vegetation Yes ❑/"NA <br />MNoF-1❑ <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well <br />Yes 2 No ❑ <br />Yes 0 No ❑ If`no' is selected, attach an accurate map to permit <br />Yes [V No ❑ <br />Permit drawing sufficient to locate well in future <br />Photograph taken and attached to record <br />OTHER: <br />Comments: <br />fVp ll�rrCliM� l� ^ (j�p �GL1/I/�(M`CX�*•cL v`xs� <br />Inspected Sy: Title: ` 4 A-Sf 6 <br />Received By: <br />Date: <br />Gu .conn <br />