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SAN JOAQUIf,1 (',,OUNTY <br /> ENIVIRONIVIENITAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209)468-3420 Fax: (209) 468-3433 )JI[eb:.�A/\kAtv.sigov.orq/ehd <br /> PUMP WSPEC[ION CHECK UST <br /> Address: Per rrj#W. <br /> VD() ? In,, ion te. <br /> 171 t <br /> CAL AV& vi 1 <br /> COMY11entS1Ar1eaSL1rPrnenfq( <br /> Parameter/Standard Meets sic s­Landards? <br /> Recommendations <br /> CEME1\7PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes 9 No F] NA[I <br /> Casing extends at least 12" above grade -Yes No E] NAE] Ii <br /> Casing extends ats' <br /> -least V above pedestal (Yes I NoEl INA D <br /> Free of cracks/contiguous with annular seal Yes [� No El NA <br /> Graded to allow drainage away from casing Yes [� NoEl NAE1 <br /> ISANITARY SEAL: <br /> Pell is sealed between pump and casing Yes No F-1 NA [I <br /> 'Sea] between all pipe columns and casing Yes V FNoE] NA ❑ <br /> ;Sounding tube/air vents sealed properly YesEl I No F-1 NA <br /> Chlorination port available and sealed properly Yes INo ❑ NA <br /> S,AMIPLE TAP AND BACKIFLOA1 PREVENTION: <br /> Non-threaded sample tap between well head andl <br /> check valve or within 3' of well head Yes N <br /> Adequately installed check valve or BFP device IYes V NoEj I NAE] <br /> No cross connections (ex.- chemical feeders <br /> 'hooked to distribution system/ag flood irrigation <br /> ifi-orn domestic supply) YeSEJ No El NA F12 <br /> ;Air gap of at least 6" (same as pipe diameter) YesEj No L__1 INA Y I <br /> 1MAINTENANCE: <br /> !Well/Pump visible and protected from damage I Yes INoE1 INA 11 <br /> Well/Pump free from excessive vegetation I Yes jNoE1 INA F1 <br /> .MISCELLANEOUS: <br /> Permit drawing represents actual location of well IYes No 0 <br /> Permit drawing sufficient to locate well in future Yes I No ❑ Wno'is selected, attach an accurate map 10 perms <br /> ,Photograph taken and attached to record Yes <br /> IOTHER: <br /> C Dnimen's: <br /> i II <br /> Cz- H - kii j, 'f' <br /> Inspected Bv: Title: <br /> Received By: I Date: <br /> rzu .,.-,r,n <br />