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l <br /> T <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1-86.8_East-Hazelton-Av-e ,_�tocL�ton. CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.siAov.org/ehd <br /> PUMP N ION .7HECKLIST <br /> Address: Perrnit#: lnsp ctio Date: <br /> Parameter/Standard Meets SJC Standards? <br /> C o m m e ntslM a as u rem entsl <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 No ❑ NA❑ <br /> Free of crackslcontiguous with annular seal Yes [ No ❑ NA❑ <br /> Graded to allow drainage away from casing I Yes 11f No ❑ INA❑ <br /> SANITARY SEAL: <br /> Well is sealed between.pump and casing Yes Q No ❑ NA❑ <br /> Seal between all pipe columns and casing Yes P No ❑_ NA❑ <br /> Sounding tube/air vents sealed properly - Yes ❑ No ❑ NA <br /> Chlorination port available and sealed properly IYes No ❑ NA❑ <br /> SAMPLE TAP AND BACKFLOW PREVENTION: <br /> INon-threaded sample tap between well head and <br /> check valve or within 3' of wellhead Yes LA No ❑ NA❑ <br /> Adequately installed check valve or BFP device Yes No ❑ NA❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No ❑ NA Ff <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA[6 <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 [1 No ❑ <br /> Permit drawing sufficient to locate well in future Yes Q No ❑ If`no`is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER: <br /> Comment <br /> nspected Byrn J Title: <br /> Zeceived By: Date: <br /> 111-4 <br />