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P Y SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />ti 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone; (209) 468-3420 Fax: (209) 468-3433 Web; www.slgoy.or /q ehd <br />PUMP INSPECTION CHECK LIST <br />Address: <br />S 5. A523� <br />Permif4: <br />TnZspection Date: <br />3�r <br />ParameterlStandard <br />Meets SJG Standards? <br />GommentslMeasurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) <br />Yes <br />No ❑ <br />NA ❑ <br />Casing extends at least 12" above grade <br />Yes EY <br />No ❑ <br />NA ❑ <br />Casing extends at least V above pedestal <br />Yes rj <br />No ❑ <br />NA ❑ <br />Free of cracks/contiguous with annular seal <br />Yes <br />No ❑ <br />NA ❑ <br />Graded to allow drainage away from casing <br />Yes [ <br />No ❑ <br />NA ❑ <br />SANITARY SEAL: <br />Well is sealed between pump and casing <br />Yes [4 <br />No ❑ <br />NA ❑ <br />Seal between all pipe columns and casing <br />Yes ESI <br />No ❑ <br />NA ❑ <br />Sounding tubelair vents sealed properly <br />YesF4 <br />No ❑ <br />NA ❑ <br />Chlorination port available and sealed properly I <br />Yes ❑ <br />No ❑ <br />NA [jl <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 />^/ <br />NA Lam' <br />Adequately installed check valve or BFP device <br />Yes Qf <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 14 <br />No ❑ <br />NA ❑ <br />Air gap of at least 6" same as pipe diameter) <br />Yes ❑ <br />No ❑ <br />NA Q/ <br />MAINTENANCE: <br />Well/Pump visible and protected from damage <br />Yes <br />No ❑ <br />NA ❑ <br />Well/Pump free from excessive vegetation <br />Yes [� <br />No ❑ <br />NA ❑ <br />MISCELLANEOUS: <br />Pen -nit drawing represents actual location of well <br />Yes <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 <br />No ❑ <br />OTHER: <br />Comments: <br />l\ <br />Inspected By: \RN's k Title: <br />RZ , � <br />Received By: Date: <br />CW norm <br />