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l <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1B68_East_fazeltonAvenu���. CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.orq/ehd <br /> PUMP INSPE I HE—K I-ST <br /> Address: O U/J J i i G (� \ 5 O Ck� Permif#1go o-7 '•-7q q 1,1 r0 jn,iafe: <br /> 'v F�J Comments/Measurements�l Il <br /> ParameterlS#andard Meets 5JC Standards? Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes No ❑ NA❑ <br /> Casing extends at least 12"above grade Yes fV No ❑ NA❑ <br /> Casing extends at least 1" above pedestal Yes Lh No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes U No [] NA❑ <br /> Graded to allow drainage away from casing Yes[ ( No ❑ NA❑I <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes - No ❑ NA❑ <br /> Seal between all pipe columns and casing Yes No❑-NA❑ <br /> Sounding tubelair vents sealed properly - Yes No ❑ NA❑ <br /> Chlorination port available and sealed properly Yes ❑ No ❑ 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 Yes ❑ No ❑ NAV <br /> Adequately installed check valve or BFP device Yes a No ❑ NA❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) I Yes ❑ No ❑ NA <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes ly No ❑ NA❑ <br /> UI/ell/Pump free from excessive vegetation Yes No ❑ NA . <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well .YesNo <br /> Permit drawing sufficient to locate well in future Yes 6,No ❑ If'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER: -- <br /> Comments: - -- <br /> nspectedBy: vow Title: V 4iinlzWt91 HP-10 <br /> Zeceived By: Date: <br /> n lnA rnnA c <br />