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r 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:wwvd.sigov.org/ehd <br /> PUMP Vi SPECTION C61ECK LIST <br /> Address: Perm �� Inspe Pion ate: <br /> 10100 W I O- S TV 0 i U rJ (�J O 0 Zo 0'7;6 <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes V1 No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes [ No ❑ NA❑ <br /> Casing extends at least 1" above pedestal Yes [ No ❑ NA❑ <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 0 No ❑ NA ❑ <br /> Seal between all pipe columns and casing Yes © No ❑ INA ❑ <br /> Sounding tubelair vents sealed properly Yes ❑ No ❑ NA 2 <br /> Chlorination port available and sealed properly Yes.Z 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 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 ❑ 1NoE1 NA M <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes 2 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 D No ❑ if'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes ['f No ❑ <br /> ®THEM: <br /> Comments: --- <br /> h s SJ� ' <br /> �---� � w-P <br /> .{ <br /> L.IPC is <br /> Inspected By: oli. title: 1 I ' f!J <br /> Received By: Date: <br /> cu n,)nn <br /> sti� �ndr. <br />