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Y SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95206-6232 <br /> Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.sjgov.orq/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address C 0 I J J F! lr � � i�Q P cfion Dafc: <br /> OF 40 tjw 1J <br /> 1 f / <br /> ParameterlStandard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes JZ No ❑ NA❑ d))MR ►S;�)o bo <br /> Casing extends at least 12" above grade Yes 2 No ❑ NA❑ <br /> Casing extends at least V above pedestal Yes No 1M NA❑ C m ^J J ��,cv� e ,4 / <br /> Free of cracks/contiguous with annular seal Yes [2 No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes [7j 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 No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑ NA 17 <br /> Chlorination port available and sealed properly Yes 0 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 ❑ INAE] <br /> Adequately installed check valve or BFP device Yes No ❑ NA❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No ❑ NA [if <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA <br /> MAINTENANCE: <br /> VVe]UPump visible and protected from damage Yes ® No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes Z No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes Q No ❑ <br /> Permit drawing sufficient to locate well in future Yes No ❑ if'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER: 1 <br /> Comments: t`'0 <br /> Cis 41I�� �'` PR <br /> 5s- �, <br /> Inspected By: YO,JA 1 J^, Title: �J1(tif <br /> Received By: Date: <br /> �u n�nn <br />