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• SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> ---- <br /> .1.868_East-Hazelfoc-Av-enu-e,_StQ-cktQn, CA 95205-6232 --- <br /> Telephone:(209)468-3420 Fax;(209)468-3433 Web:www.sigov.orq/ehd <br /> PUMP PECTFON GRIDGK-LIST - - -- - - - <br /> Address: Per 1 Inspe tion ate: <br /> ON f <br /> 7 2-SI14- <br /> Parameter/Standard Meets SJC Standards? CommentslMeasurements/ <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 1" above pedestal Yes [M1/] No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal IYes No ❑ NA❑ <br /> Graded to allow drainage away from casing I 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 tubelair vents sealed properly - Yes ❑ No ❑ NA b' <br /> Chlorination port available and sealed properly I Yes Lk No ❑ INA❑ <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 systemlag flood irrigation <br /> from domestic supply) Yes ❑ No ❑ NA <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ I No ❑ NA <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage I Yes ,No ❑ NA❑ <br /> Well/Pump free from excessive vegetation IYes4Z INon NA <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well .Yes No ❑ <br /> Permit drawing sufficient to locate well in future Yes 2 No ❑ if'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes No El <br /> OTHER: <br /> Comments: <br /> l <br /> Inspected By: G Title: 5) <br /> Received By: Date: <br />