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• SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1.86.8_East_HazeIto n_Avenue,St-2cktw, CA 95205-6232 _ <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.slgov.org/ehd <br /> PUMP IWE-GTFGWG E-GK-LIST — <br /> A re Pern #: Ins ection0� Date: <br /> 0 0 E Aa VaC 4' Z. W bc) 3 j, S 8 11 l-1- <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 No ❑ NA❑ <br /> Casing extends at least T' above pedestal Yes [jA No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes No ❑ NA❑ <br /> Graded to allow drainage away from casing lYes IND ❑ 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 KK <br /> Chlorination port available and sealed properly Yes 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 KI 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 ❑ No ❑ NA IV <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No [:1NA El <br /> Well/Pump free from excessive vegetation Yes ® No ❑ NA[] <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well .Yes NJ 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 YesY No ❑ <br /> OTHER: <br /> Comments: <br /> s N_e�aA � <br /> Inspected By V! <br /> Received By: Date: <br />