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SAfe JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> 1 efephone:(209)468-3420 Fax: (209)468-3433 Weir:www.sjgov.orq/ehd <br /> _ PUMP INSPECTION CHECK LIST _ <br /> Address: Permit#: � Inspection Date: <br /> 009,b6 0 0 3l.� S 1 i q <br /> Parameter/standard Meets SJC Stanidards? ConimentslMeasurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes No ❑ NA❑ <br /> Casing extends at least V above pedestal Yes No ❑ NA ❑ <br /> Free of cracks/contiguous with annular seal AYes <br /> No ❑ NA E]Graded 'io allow drainage away from casing No ❑ NA El <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes No ❑ NA❑ <br /> Seal between all pipe columns and casing Yes No ❑ NA❑ <br /> Sounding tube/air vents sealed properly - Yes No [:1NA❑ <br /> Chlorination poll available and sealed properly Yes No ❑ NA❑ <br /> SAMPLE TAIL AND BACKFLOW PREVENTION: <br /> Non-threaded sample tap between well head and <br /> check valve or within 3' of well head Yes No ❑ NA <br /> Adequately installed check valve or GFP device Yes No ❑ NA ❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> Trom domestic supply) Yes ❑ No NA <br /> Air gap of at least 6" (same as pipe diameter) IYes..0 No ❑ NA <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No ❑ INA ❑ <br /> Well/Pump free from ex-cessive vegetation IYes No ❑ NA ❑ <br /> MlISCELLANEOUS: <br /> Permit drawing represents actual location of well IYes No ❑ <br /> Permit drawing sufficient to locate well in future IYes 4 No ❑ if'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes A I No ❑ <br /> OTHER: <br /> Comments: <br /> S,� '���M -�c1b�, off✓ �v.� <br /> I <br /> i <br /> Inspected By: Title: Y/`\ SS� I <br /> Receives! By: Date: <br /> 11nA InnAG <br />