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SAKI JOAnauiw Gout�,n( <br /> ENIVIRONIMENTAL HEAL TFI DEPARTMENT . <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Tefephoae:(209)468-3420 Fax: (209)468-3433 101,16b:1[nyw.sj.q&v,orq/elId <br /> PUMP INSPELTIOW GHECI,', UtS'T <br /> ,ddr6ss: Pers-I-Riz: Inspection Date: <br /> iMA tW& JL kA <br /> ConinienislMeasureme <br /> ParaiiieterlStaiiclard Nfieets SJC Stamidards? RC-GOMY11eildatimis <br /> 10EMENT PEDESTALS <br /> Dimensions of surface sea[ (Zxj'A" mininium) IYes No ❑ 1\A 1:1 1 <br /> -Casing-extends at least 12" above grade IYes I No El INAE] I <br /> Casing extends at least V above pedestal Yes Ij No Ej NAE] <br /> Free of cracks/contiguous with affllUlal-seal Yes F\fi No F-I NIA 0 <br /> Graded to allow drainage away from casing Yes Lq NoEl 17A El <br /> SANTTAIW SEAL: <br /> IVVell is sealed betvveeh, NA[1 <br /> Yes No <br /> Seal between all pipe COILInins and casing Yes L] INoE1 I IIJA[I I <br /> I <br /> Sounding tube/air vents sealed properly i <br /> Yes No ❑ NAE1 I <br /> Chlorination port available and sealed properly I Yes No INA [I <br /> 9MhPLC TAP AND BACKFLOW PREVEi\,lTlON-. <br /> ..' 'N-on-threaded sample tap between well head and <br /> :'check valve or within Tof wellhead Niles Fj No Ell NA ❑ <br /> Adequately installed check valve or BFP device Yes No 0 NAE1 li <br /> No cross connections (ex: chemical feeders <br /> hooked to disiribLltbrl systerh/ag flood irrigation <br /> TI.om dorrrestic supply) YesEl No I NA <br /> Air gap of at leant 6;' (same as pipe diameter) I YesEl No [:1 <br /> P <br /> MAI NTE NANC E <br /> Well/Pump visible and protected from darnage Yes JQJ INo n INA [] I <br /> X ssive vegetation -1�, <br /> ,Well/Pump free frorn exces tation Yesa NoEl I-NA <br /> 11AISCELLANEOUS: <br /> i Permit drawing represents actual location of well Yes Aj I NoEl <br /> iPern-,it drawing sufficient'Lo locate wel! ill fUtUre YesNo Ellf'no'is selected.attach an accuraten-iap to permit <br /> Photograph takeni.A-tGclied to record IYes j I NoF1 <br /> OTHI ER: <br /> I ri s p c-c te ci Ik y: SIM <br /> Received By: D2fe: <br />