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SAINv JO/3,0-Ull,,'COUNTY <br /> &,mRONIMENTAL HEALTH DEPARTMIENT <br /> 1868 East Hazelton AvellUe, Stockton, CA 95205-6232 <br /> Tefcaphonte:(209)468-3420 Fax., (209)460 X433 Vj/eb:yuvm.sigov.org/e!ld <br /> PUMP IMSPE(DTION CHECK LIS'.1' <br /> Ad d I ds S: Permite.: inspection Date: <br /> ParanneterlStandard Meets SJC Standards? Rc-commendati <br /> _clil!22a__—, <br /> GENIENT PEDESTAL <br /> Dimensions Of SUrface seal (2'x2'x4` minimum) Yes Ld No 0 INA 0 <br /> Casing extends at least 12' above grade Yes N No 0 INAE] I <br /> Casing extends at least V above pedestal Yes No ❑ NAE1 I <br /> Free of crackslmlltlgUOUS with allrU121-seal —Yes No -EI-11 I NAE1 I <br /> Graded to a.llow drainage away from casing Yes I No ❑ INA 0 <br /> SANITARY SEAL: <br /> Well is sealed bethNeen ID1.11-111D and casing IYes I No ❑ INA 0 1 <br /> Seal betv�leerl all pipe columns and casing iYes ❑ No L—sj' NAE] <br /> Sounding tube/air vents sealed properly Yes El INoE1 NA[j I <br /> Chlorination poll available and sealed properly Yes 0 1 No VI NAE] I <br /> S. Nq P L E TAP A N D BA,G K F L.0 Vil P R,EV E Nt T 10 N: <br /> lNon-threaded sample t-ap between well head and� <br /> check valve or within 3' of well head YesE] No ❑ NA <br /> Ac,leqL!2..!Lely installed check valve or BFP device I Yes El No NA El <br /> 1,,Jo cross connections (ex: chemical feeders <br /> hooked to distribution systlern/ag flood irrigation <br /> TI-0111 don-iestic supply) Yes Kf NoEl NIA 11 <br /> Air gap of at least_6:' (sarne as pipe diameter) YesEl No El NA [I I <br /> Nq A I N1 T-E N laN C E <br /> ;Well/Pump visible and protected from damage Yes No Ll I NAL] I' <br /> Well/Pump free from excessive vegetation I Yesj No ETINAFJ I <br /> NUSCELL-AtJ]HOUS., <br /> Permit draming represents actual location of well I Yes I No [:1 <br /> Permit drawing suffici.eni to locate well in future I Yes No El lf'no'is selects'd,attach an accurate map to permit <br /> Photograph taken and attached to record I e INoE1 <br /> I OT 1-1 E R: <br /> com 1-11&Fits: <br /> rx <br /> Inspected By: Title:\V� <br /> J <br /> Received By: Date: <br />