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BAN J'OAQUIN. C",OUKITY <br /> El',,IVI RON IMENTAL HEALTH DEPARTMENT <br /> 1868 East FlazeltOn Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 F:'ax. (209) 468-3433 I/1/6b:w\AjV,',sjpov.oMkb-d <br /> PUMP 11INSPE CT101,4 CHECK LIST <br /> Address, Insp, tion Vate: <br /> D-1.0-F1 F, - H-.W L i f�j-b&J 7 Y,;-) TW/,� <br /> PararnererlStandard Alfleets SJC Stalidai-ds; Comm entslftleaSUrernentsl <br /> Recommendations <br /> -G1r-_MElJ1'T' PEDES TAL-. rli <br /> Dimensions of surface seal (2'x2'x4?' rninirnurn) Yes FA No IM INA F-1 I <br /> Casing extends at least 12" above grade Yes No F-1 INA ❑ I <br /> Casing extends at least Vabove. pedestal Yes No F1 INA 0 <br /> Free of cracks/contiguous Midi annular seal IYes No El INA 0 <br /> lGraded to allow drainage away from casing IYes fv' NoD INAD <br /> 'SANITARY SEAL: II <br /> IVVell is sealed between IDUMID and casing Yes S? NA El <br /> .Seal between all pipe columns and casing IYes NA ❑ <br /> Sounding tUbelair vents sealed <br /> ealed properly Yes � INoD NAD <br /> 'Chlorination port available and sealed properly I Yes V INoE1 NA 0 <br /> SJ-UVIPLE TAP AND BAGULOAT PREVENTION: <br /> heck valve or within 3' of well head Yes�61 <br /> Non-threaded sample tap between well head and <br /> cN o OJNA 0 II <br /> !.,--, <br /> A <br /> dequa'Lely installed check valve or BFP device IYes V No F-1 NA [:1 <br /> No cross connections (ex: chemical feeders <br /> !hooked to distribution syste-rn/ag flood irrigation <br /> ;from domestic supply) YesE] IN o F-1 NA <br /> Air gap of at least 6" (same as pipe diameter) IYes 0 INo 01 INA <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage IY No 0 INA F1 I <br /> Well/Purnp free frorn excessive vegetation I Yes INoE1 INA[I I <br /> MISCELLANEOUS: <br /> Permit drawing represents aCiLial location of well ]Yes C2 No [:] <br /> Pei-mit drawing sufficient to locate well in future IYes NoEl 11'no'is selected, attach an accurate map to permit <br /> lPhotograph taken and attached to record IYes No <br /> 1C LER: <br /> Gonni-nents, <br /> !i <br /> /A <br /> inspected B <br /> Title: <br /> Received By: --_—-- I Date: <br /> . <br /> r-LJ A-,)nn <br />