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SANv JOAQUIN COUNTY <br /> B,wIRONNIEN IAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 9520.'5-6232 <br /> Tefeaphone:(209)468-3420 T.."ax: (209)468-34303 bfileb: yfim.siggy.orglelid <br /> PUMP IMPECTION GHECVC, LIST <br /> Permit#.; T Inspection Date: <br /> FAM -� ' u� -[D/L <br /> J\) 0c)sc� <br /> % <br /> Paranneterl-S-1.'andard Meets SJC Standards? Rccomynendattiojis <br /> (.-'E1YT1Et-JT PEDESTAL: <br /> Dimensions Of surface sea[ (2'x2'x4' minimum) IYes g]. No [:1 INA 0 <br /> -Casing extends at least 12" above grade —FYes —9 NoF-1 INA 0 1 <br /> Casing extends at least V above pedestal Yes M No El NA R <br /> Free of cracks/contiguous with ar)FILIlar seal Yes rj No R NAE] <br /> Graded to allow drainage akqay from casing I Yes [j ,NoEl INAF❑I I <br /> SANITARY"SEAL: <br /> Well is sealed between pump arid casing Yes R6 No F1 INA 0 <br /> Seal between all pipe columns and casing Yes NoEl INA D <br /> Sounding tube/air vents sealed properly Yes No F1 INA El <br /> Chlorination port available and sealed properly Yes & No [:11 NAE] <br /> SAMPLE TAP AND SAC[-TLOVif PREVENTION: <br /> Non-threaded sample tap between well head and <br /> check valve or within T of well head �Yesj No 0 NAE] <br /> Adequately installed check valve or BFP device F4 No El INA ❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution systern/ag flood irrigation <br /> from dorriestic SLIPI)ly) Yes j NoE] NAE], <br /> Ali-gapofat least 61' (same as pipe diameter) I YesF1 INoE1 NA <br /> MAINTLE-:NANCE: <br /> r I <br /> ;Well/Pump visible and protected from darnage I Yes No ❑ NA❑ <br /> ,Well/Pump free from excessive vegetation IYes No ❑ INA 1:1 1 <br /> FIASCELL AN EHOUS % <br /> Permit drawing represents actual location of vvell Yes INoE1 <br /> I Permit drawing Klfficientto locate well in future YesNoEl Ej Uno'is selected,attach an accurate map to permit <br /> N <br /> 1piiotograph taken and attached to record Yes tj NoEl <br /> 10'rliER: <br /> ii <br /> lComments: <br /> ITitle: <br /> Received By: D af e: <br />