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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />-- <br />.1.868_East_Hazelton-Av-enue,_St.Qekt4n. CA 96206-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />PUMP INSPECTION CHECKLIST <br />s: <br />Ad�q65s 6-7!fi GT -rKl c <br />Perms : <br />W 0 0 36 31 a <br />Inspe -tion Date: <br />1/0 a�/1 <br />Parameter/Standard <br />Meets SJC Standards? <br />CommentslMeasurementsl <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal 2'x2'x4" minimum <br />Yes [Z <br />No ❑ <br />NA ❑ <br />Casing extends at least 12" above grade <br />Yes <br />No ❑ <br />NA ❑ <br />Casing extends at least 1" above pedestal <br />Yes ( <br />No ❑ <br />NA ❑ <br />Free of cracks/contiguous with annular seal <br />Yes <br />No F] <br />NA El <br />Graded to allow drainage away from casing <br />Yes [a <br />No ❑ <br />NA ❑ <br />SANITARY SEAL: <br />Well is sealed between pump and casing <br />Yes - <br />No ❑ <br />NA ❑ <br />Seal between all pipe columns and casing <br />Yes K2 <br />No ❑ <br />NA ❑ <br />Sounding tube/air vents sealed properly - <br />Yes ❑ <br />No ❑ <br />NA <br />Chlorination port available and sealed properly <br />I Yes bZ <br />lNo ❑ INA <br />❑ <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 10 <br />No ❑ <br />NA ❑ <br />Adequate!y installed check valve or BFP device <br />Yes EZ <br />No ❑ <br />NA ❑ <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) <br />Yes ❑ <br />No ❑ <br />NA <br />Air gap of at least 6" (same as pipe diameter) <br />I Yes ❑ <br />INo ❑ <br />NA <br />MAINTENANCE: <br />Well/Pump visible and protected from damage <br />Yes &a <br />o ❑ <br />NA ❑ <br />Well/Pump free from excessive vegetation <br />IYes ® <br />I No ❑ <br />NA El <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well <br />. Yes to <br />No ❑ <br />If'no' is selected, attach an accurate map to permit <br />Permit drawing sufficient to locate well in future <br />Yes ® <br />No ❑ <br />Photograph taken and attached to record <br />Yes ❑t/j <br />No ❑ <br />OTHER: <br />Comments: <br />�-►� r ►-ur► �, yea I � <br />Inspected By VOLAI S� <br />Title: <br />Received By: <br />Date: <br />-1 1.1!1.1 C <br />