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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.sjgov.orq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Addres PermsInspe ion <br /> 494 E - LEDN � 1) )tvrr STbCkn� �J 003921) o �z. lip: <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> 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 2 No ❑ NA❑ <br /> Casing extends at least V above pedestal Ye No [ NA❑ Ca)'k 4,6 /V -A ► <br /> Free of cracks/contiguous with annular seal Yes © No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes [� No ❑ NA ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes No ❑ NA ❑ <br /> Seal between all pipe columns and casing Yes 0 No ❑ NA ❑ <br /> Sounding tubefair vents sealed properly Yes ❑ No ❑ NA Q' <br /> Chlorination port available and sealed properly Yes V No ❑ NA ❑ <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 ❑ NA ❑ <br /> Adequately installed check valve or BFP device Yes 5Z No ❑ NA ❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No ❑ NA <br /> Air gap of at least 6" same as pipe diameter) Yes ❑ INo ❑ NA Rr <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes 12 No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes ' No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes No ❑ <br /> Permit drawing sufficient to locate well in future Yes a No ❑ If'no'is selected, attach an accurate map to permit <br /> Photograph taken and attached to record Yes Vr No ❑ <br /> OTHER: <br /> Comments: <br /> C06LcJ,,O.;,s purl c( ia�0W Pec&-41 <br /> 1Qt.til`cyet. � cl > Lv� i1 � V /h <br /> Inspected By: Gtln SO Title: <br /> Received By: Date: <br /> MLA n)nn <br /> aid �nc <br />