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UIP'41Y VVri W,V11Y V'lJV1Y1 7 <br />EN1/fRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone; (209) 468-3420 Fax; (209) 468-3433 Web: www.sigov.om/ehd <br />PUMP INSPECTION CHECK LIST <br />Addres Pe <br />j A RL/rJ C-JCA,Lo /i 0 -7 <br />Inspe on pate: <br />1/0 E0 <br />Parameter/standard <br />Meets SJC Standards? Comments/Measurements/Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) <br />Yes W <br />No ❑ <br />NA ❑ <br />Casing extends at least 12" above grade <br />Yes [2 <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 M <br />No ❑A <br />ElN <br />Graded to allow drainage away from casing <br />Yes [`� <br />No ElNA <br />❑ <br />SANITARY SEAL: <br />Well is sealed between pump and casing <br />Yes [0 <br />No ❑ <br />NA ❑ <br />Seal between all pipe columns and casing <br />Yes ® <br />No ❑ <br />NA ❑ <br />Sounding tube/air vents sealed properly <br />Yes ❑ <br />No ❑ <br />NA Sj <br />Chlorination port available and sealed properly <br />Yes <br />No ❑ <br />NA ❑ <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 [2 <br />No ❑ <br />NA ❑ <br />Adequately installed check valve or BFP device <br />Yes [ <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 />Yes ❑ <br />No ❑ <br />NA <br />MAINTENANCE: <br />VVell/Pump visible and protected from damage <br />Yes [0 <br />No ❑ <br />NA ❑ <br />Well/Pump free from excessive vegetation <br />Yes ] <br />No ❑ <br />NA ❑ <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well <br />Yes Fv� <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 />Inspected By;jYaTitle <br />so <br />L ' fT ' Ftf� )J t�,yf <br />Received By: <br />Date: <br />T=LJ nonn <br />