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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209) 468-3420 Fax:(209)468-3433 Web:wvvw.sigov.omg/ <br /> PUMP INSPECTION CHECK LIST <br /> Address; Permit4: Inspection Date: <br /> PM �S�P��.�tJ qS 20 WQ bb oVIwv <br /> Parameter/StandardI Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes Id No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes 14 No ❑ NA❑ <br /> Casing extends at least V above pedestal Yes No ❑ NA <br /> Free of crackslcontiguous with annular seal Yes F4 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 No❑ NA❑ <br /> Seal between all pipe columns and casing Yes Ej No ❑ NA❑ <br /> Sounding tube/air vents sealed properly Yes No ❑ NA❑ <br /> Chlorination port available and sealed properly Yes J 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 ❑ No NA ❑ `-4 <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 11 <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ jNoD NA FQ <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 A JNo ❑ <br /> Permit drawing sufficient to locate well in future Yes No ❑ If'no'is selected, attach an accurate map to permit <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER: <br /> Comments: <br /> NON T_R,"9-f 0 CD®ffhPh fVtb M f 5 5 rAvti <br /> Inspected By: Title: <br /> Received By: Date- <br />