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SAN JOAQUIN. (",',OUNTY <br /> DwiRONIMENTAi-HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209)466-3420 Fax: (209) 468-34-33 Vi/6b:vwvw.sjqov.oM�/�ed <br /> PUMP M`-'PECTION CHECK LISIF <br /> IAddress: Permifl-V: %SZ�id� <br /> OZq7 E- IAPAPOPr(–A-m PDP,0 0-M / 934�— <br /> Pararn eterlo"tan Card Meets SJC Standards? commentsfArleasurernenis/ <br /> Recornrilendaiions <br /> C E M E KI T P ED E 8 T AL <br /> Dimensions of surface seal (2'x2'x4" rninimurn) Yes No F] INAEJ <br /> �Casing extends at least 12" above grade Yes No El INA R <br /> )Casing extends at least Vabove pedestal Yes g I NoE] I NAE] <br /> Free of cracks/contiguous with annular seal Yes WINo El INA R <br /> Graded to allow drainage away from casing Yes INotN�AERI I <br /> SANITARY SEAL: <br /> Well is sealed between pump and ca,, Yes INoF-1 NA ❑ I <br /> Sea] between all pipe columns and casing )Yes No.R I NA R I <br /> Pounding tube/air vents sealed properly Yes ❑ No R INA W <br /> 'Chlorination port available and sealed properly Yes No 0 INAE] I —————-- <br /> SAMPLE TAP -AND BACKFI-0141 PREVENITION-1. II <br /> Non-threaded sample tap between well head and <br /> c.heck valve or within 3' of well head Yes W, 1NoO NAE1 <br /> Adequately installed check valve or BFP device Yes V INoF-1 I NAE1 <br /> No cross connections (ex: chemical feeders II <br /> !hooked to distribution systerri/ag flood irrigation <br /> lfi-om domestic supply) YesEj- No F-1 NA W1 Ij <br /> Air gap of least &' (same as pipe diameter) Yes 0 INo F1 ,NA <br /> FMAINTENANCE: <br /> Well/Pump visible and protected from damage Yes [V No [-] NAE] Ij <br /> Well/Pump free,from excessive vegetation Yes,Z INo [:1 NAE1 <br /> 11MISCE1_LANEOUS: ji <br /> Permit drawing represents actual location of well IYes I No <br /> 1P raw <br /> e Yes No ❑ ff'no'iS Selected,aftach an accurate map to permit <br /> Permit drawing sufficient to locate well iii.future I El <br /> P P1 <br /> hotograph'Laken and attached to record Yes No ❑ <br /> OTH LE R: <br /> Co nn rn e n ts, <br /> f <br /> li <br /> )Inspected By: <br /> 4 <br /> Il Received By: D a t G.- <br /> F--W <br />