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k <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fox: (209)468-3433 Web:www.sigov.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address E (6 f''e r Rb b Perrrtit 3S o a n 1n; coon Date: <br /> V` I/J �J 0 0 Q /2 <br /> Parameter/Standard Meets SJC Standards?? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes 0 No ❑ NA ❑ <br /> Casing extends at least 12" above grade Yes 0 No ❑ NA ❑ <br /> Casing extends at least V 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 m No ❑ NA ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes W No ❑ NA ❑ <br /> Seal between all pipe columns and casing Yes E2 No ❑ INA ❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑kNAO <br /> AJ <br /> Chlorination port available and sealed properly Yes No ❑ <br /> SAMPLE TAP AND BACKFLOW PREVENTION: <br /> Non-threaded sample tap between well head and r/a <br /> check valve or within 3' of well head Yes ❑ No Q NA ❑ <br /> Adequately installed check valve or BFP device Yes 0 No ❑ NA ❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) I Yes ❑ INo ❑ INA [✓� <br /> Air gap of at least 6" (same as pipe diameter) IYes ❑ I No INA [� <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes [a No El <br /> NA <br /> Well/Pump free from excessive vegetation Yes [✓]� No ❑ NA ❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes V1 No ❑ <br /> Permit drawing sufficient to locate well in future Yes [Z No ❑ If'no'is selected, attach an accurate map to permit <br /> Photograph taken and attached to record Yes [0 No ❑ <br /> OTHER: <br /> Comments: <br /> rjo yenl,Ir1 �3 <br /> Inspected By: A,r, �� Title: � � P-SS �CcH <br /> Received By: Date: <br />