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r 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.orq/ehd <br />PUMP INSPECTION CHECK LIST <br />s: <br />S �SIvT} Permrt#. 4S-�Sp/�� / <br />6Z D O -7-7-7-7 <br />Parameter/Standard Meets SJC Standards? Commenfis/r menfisl <br />CEMENT PEDESTAL: <br />Yes ❑ <br />INo ❑ <br />Recommendations <br />Dimensions of surface seal (2'x2'x4" minimum) <br />Yes V <br />No ❑ <br />NA ❑ <br />Casing extends at Ieast 12" above grade <br />Yes <br />No ❑ <br />NA ❑ <br />Casing extends at least V above pedestal <br />Yes [V <br />No ❑ <br />NA ❑ <br />Free of cracks/contiguous with annular seal <br />YesNo <br />❑ <br />NA ❑ <br />Graded to allow drainage away from casing <br />Yes ❑ <br />No ❑ <br />NA ❑ <br />SANITARY SEAL: <br />Yest-g-n <br />is selected, attach an accurate map to permit <br />Well is sealed between pump and casing <br />Yes <br />No ❑LE <br />Yes <br />Seal between all pipe columns and casing <br />Yes <br />No ❑ <br />Sounding tube/air vents sealed properly <br />Yes ❑ <br />NoVChlorination <br />port available and sealed properly <br />Yes <br />No ❑ <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 ❑ <br />No <br />0 S <br />NA ❑ <br />Adecivate[y installed cher:k valva nr RFP rlravirr= <br />vao G7 <br />nr„ I—f INIA <br />r—I <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) <br />Yes ❑ <br />INo ❑ <br />V <br />NA <br />Air gap of at least 6" (same as pipe diameter) <br />Yes ❑ <br />INo ❑ <br />NA <br />MAINTENANCE: <br />Well/Pump visible and protected from damage <br />Yes 2 <br />No ❑ <br />NA ❑ <br />Wel[/Pump free from excessive vegetation <br />Yes <br />tNo ❑ INA <br />❑ <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well <br />Yest-g-n <br />is selected, attach an accurate map to permit <br />Permit drawing sufficient to locate well in future <br />Yeso' <br />Photograph taken and attached to record <br />Yes <br />OTHER: <br />Received By: <br />. 1 0L." <br />cu n )nn <br />Date: <br />