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SAM JOAQUIN] GOUN <br /> BwRoi\1mjE1`,1TAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Tefeapftoae:(209)468-3420 Fax., (209)468-3433 11146b:vNm.sjqov,org/ehd <br /> - -- ---` --- . PUMP MISPECTIONI CHECK' 11-IS-21' <br /> Inspection Date. <br /> Addr6ss: Permit#.: <br /> I 0 17-1 0 I L <br /> A ' Coir�r.lef-i�s/measLileriieii,LSI <br /> ParameterlStandard _j KheetS SJC St2ndards? Recommendations <br /> CEIVIENT PIEDESTAL. <br /> Dimensions of surface seal (2'x2'x4` minimum) 1'es No El INA 0 <br /> Casing extends at least 12" above grade Yes L-J No 0 NA❑ <br /> Casing eAxtends at least V above pedestal ❑Yes [� No [:] NAE1 I <br /> Free of cracks/contiguous with annU121-seal Yes Ij NoEl I NIAE] I <br /> Graded to allow drainage away from casing1,"es r-i j <br /> 1L�j T <br /> ffINAE1 I <br /> SANITARY SEAL: <br /> Well is sealed between punip and casing Yes No F1 INA D I <br /> Seal between all pipe columns and casing !Yes [A— No F-1 I NAE] <br /> Sounding tube/air vents sealed properly I Yes J No ❑ NAE1 <br /> Chlorination poll available and sealed properly—]YesEl No [:] NA j <br /> SAMPLETAP ANM BACKFLOW PREVENTION: <br /> Non-threaded sample'Lap between we'11 head and <br /> check valve or within T of well head �Yes 0 1\0 ❑ NIA d <br /> Adequately installed check valve or BFP device -Yes j NoEl I MAEJ <br /> No cross connections (ex: chemical feeders <br /> I hooked to distribution system/ag flood irrigation <br /> TI-Om dornestic supply) YesEl No [t NAF-1 <br /> Air gap of at least 663' (same as pipe diameter) Yes El INoD NAM I <br /> MAINTENANCE: <br /> 1 - ❑ INA [:] <br /> VVell/Pump visible and protected from damage Yes No <br /> - <br /> Well/Pump free frown e,cessiv e vegetation Yes No ❑ I NA ❑ 1 -4 <br /> FO I C E L L.A N E-0 L 1i S <br /> i Permit drawing represents actual location of well IYes No ❑ I <br /> Permit drawing suff iciest'Lo locate well in fuiure Yes NOEI rno'is selected,attach an accurate map to permit II <br /> Photograph taken and attached to record Yes <br /> OTHER: <br /> Comments: <br /> 111SPeC-Led y: <br /> L B MAW ITitle: <br /> Received By: Date: <br />