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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 9868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.slclov.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: (� c (� / ) q <br /> 1 C� s(L{�' L�� L(/`� O 6 P�� �n 30 Inspe fion D te: <br /> 03 to � �� <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❑ D pit, 6eM_ei►vf <br /> Casing extends at least 12" above grade Yes ❑ No ❑ INAR �, <br /> Casing extends at least 1" above pedestal Yes ❑ No ❑ I 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 52" No ❑ NA❑ <br /> Seal between all pipe columns and casing Yes 9 No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑ NA <br /> Chlorination port available and sealed properly IYes a 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 Q No ❑ NA ❑ <br /> Adequately installed check valve or BFP device Yes V 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[Z <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes 2 No ❑ <br /> Permit drawing sufficient to locate well in future Yes [2 NO ❑ lf'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes [7� No ❑ <br /> OTHER: <br /> Comments: <br /> c <br /> ins 0c, Q <br /> Inspected By: QUA ' b^ Title: ^�• /�f,r(`J T�ly <br /> Received By: Date: <br /> cu ��nn <br />