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AkF <br /> Sjut!J o i�,nau i iw C 0 U N TY <br /> BvIRONIN/JENTAL HEAL—1 H DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Tefe;phone:(209)468-3420 F-ax: (209)468-3433 111,feb:vM1v.si-gov,orQ/ehd <br /> PUMP INSPECTM �i1JQ00, LUST <br /> Address: Permit4: Ins n <br /> ,,ectl Date: <br /> �'�5��._^ W � lt'� U�2�4 _ <br /> ParameterlStandard hheets ISJC Standards? <br /> Recommendations <br /> CEMIENT PEDESTAL <br /> Dimensions Of surface sea[ (2'x2'x4" minimum)--Yes No [j NA El <br /> Casing extends at least 12" above grade Yes Lj No ❑ NA F-1 <br /> Casing Extends at least V above Pedestal Yes No [] NAE] <br /> Free of cracks/contiguous vvith annular seal Yes No 0 NA F-1 <br /> Graded to allow drainage away from casing Yes No [j I_NAE1 I <br /> Sl�� A 1,41 FT"I RY S E A L: <br /> Well is sealed between pump and casing No ❑ NA❑ <br /> Seal between all pipe columns and casing No NAEJ <br /> SOUndingt-Ubelair vents sealed properly Yes El No D NA <br /> Chlorination pail available and sealed properly I Yes j INo D INA 0 1 <br /> SAMPLETAP ANID BACKFLOW PREVEIITIONI: <br /> Non-threaded sample tap between well head 211d <br /> check valve or within T of well head )/ 0 ❑ �NA <br /> Adequately installed. check valve or BFP device I Y No (I NAO <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution systern/ag flood irrigation <br /> I- <br /> T)orri domestic supply) Yes El No III NA D <br /> .Air gap of at least 61' (same as pipe diameter) YesEl No DINA St I <br /> r <br /> i MAINTENANCE: <br /> Well/Pump visible,.. an-d- jDrotect-e.d from-i damage I Yes No ❑ INA.0-1- <br /> Well/Pump free from excessive vec)CLCALioll IYes 9 jNoEI\JAE] I <br /> MISCELLAtiEOUS: <br /> Permit dravving represents actual location of'vvell Yes No ❑ <br /> Permit dra\,%(ing sufficient to locate well in future YesNEl❑oIf no'is selected,a-ULach an accurate!rap to permit <br /> Photograph taken and attached to record Yes III No El <br /> iOTHER: <br /> 'Comments: <br /> Inspected By: Title: <br /> Received By: D at e: <br /> 7 <br />