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SAN JOAOUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Ha-zelton Avenue, Stockton. CA 95205-6232 <br /> Telephone:(209) 468-3420 Fax: (209) 468-3433 Web:www.sigov.org/elid <br /> PUMP INSPECTION CHECK LIST <br /> Address: Permit#: Inspection D te: <br /> Parameter/Standard Meets SJC Standards? Cornments/Measurements/ <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 1 above pedestal Yes No ❑ NA ❑ <br /> Free of cracks/contiguous with annular seal Yes I JNoE] INAD <br /> Graded to allow drainage away from casing Yes No ❑ INA ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes j No ❑ NA ❑ <br /> Seal between all pipe columns and casing Yes J No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yes No ❑ NA ❑ <br /> Chlorination port available and sealed properly (Yes No ❑ NA ❑ <br /> SAMPLE TAP 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 BFP device Yes No ❑ NA ❑ <br /> No cross connections (ex: chemical feeders I <br /> hooked to distribution systern/ag flood irrigation <br /> from domestic supply) Yes ❑ �No NA ❑ <br /> Air gap of at least 6' (same as pipe diameter) Yes ❑ No ❑ INA j I _ <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes j No ❑ NA ❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well _ Yes No ❑ <br /> Permit drawing sufficient to locate well in future Yes No ❑ If'n'-'Is selected.attach an accurate map to permit <br /> Photograph taken and attached to record jYes [� No ❑ <br /> OTHER: <br /> Comments: <br /> M�T To L3 wt t P, C-N-P-�A <br /> �f ,- ) 0/2511 6" ; N0 <br /> VO;c�L Mor M � 14 6- <br /> AP0 X15 (- P <br /> 5u114M &,5 <br /> Inspected <br /> n <br /> Inspected By: <br /> Received By: Date: <br /> EH _ <br />