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SAN'jOAQUIN COUNTY <br /> EimivIRONIMENTPL HEALTI H DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> TefejahORG:(209)468-3420 F-ax: (209)4.`68-334333 <br /> 68-30433 1,11,46b:vyvpAt.sjqov,orq1ehd <br /> PUMP NSPECTMN HUST <br /> Address: Per,-nit=: Inspection cte: <br /> 0 10 <br /> MIA 0 <br /> II ParanneteriStaild2rd hfieets SJC Standards? con-imentsiRecommendations <br /> CENIENT PEDESTAL: <br /> Dimensions Of surface seal (2'x2'x4l' minimum) Yes dj I No 1-1 INAD <br /> Casing-extendsat least 12" above grade Yes J] No F1 I NAE1 <br /> Casing e.\/\,tejids at least V above pedestal Yes a No [:1 INA n I <br /> Free of cracks/contiguous vvith annular seal Yes jNoF1 INAF-1 I <br /> Graded to allow drainage away from casing Yes [t INo 0 INAE] I <br /> SAI <br /> , NIFFARlY SEAL <br /> Well is sealed between pump and casing Yes Ej NoDINAD <br /> Seal between all pipe columns and casing Yes No 0 NA <br /> /'CA <br /> SOLII1dirIg-t-LIlDe/2i1-vents sealed properly jYe s ll\)oE] NA <br /> Y <br /> Chlorination port available and sealed properly I Yes ❑ No 0 INA <br /> SAMPLE 'l,"AP AKID BACKIFLOW PREVENTION: <br /> Non-threaded sample tap between well head and <br /> check valve or within 3' of well head YesE] No E] NA <br /> Adequately installed check valve or BFP device IYes J No [:1INA ❑ I <br /> No cross connections (ex: chemical feeders,. <br /> hooked to distribution system/ag flood irrigation <br /> Trom domestic supply) lyes � No E] NA <br /> Air gap of at least 6" (same, as pipe diameter) YesEl jNoO NA <br /> MAINIT11-NANCE: <br /> "Veil/Pump visible and <br /> d protected from darnage Yes No ❑ <br /> NIA <br /> VVell/PLIMID free from excessive vegetation iYes No [:] NAE1 <br /> NUSCELLANEOUS: <br /> Permit dravving represents actual location of well Yes No ❑ <br /> 41 <br /> Permit- drawing sufficient to locate welt in fu'iure YesI EJ <br /> Nil <br /> Photograph taken and attached to record Yes I No <br /> ❑ <br /> 7VF I--11 E R: ------ <br /> ��UN cr\�K- <br /> lk <br /> Inspected Gy: Title: <br /> ji Received By: Date: <br />