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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1-868_East-Hazelton_Avenue,Stockton,-CA 9520576232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigoy.om1ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Permit#: Insp cti Date: <br /> o,,�.tr�e S po752o7 '5 17 <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal 2'x2'x4" minimum Yes Pr No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes[x No ❑ NA❑ <br /> Casing extends at least 1" above pedestal Yes No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes ❑' No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes a No ❑ NA❑ <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 2 No ❑ NA ElChlorination port available and sealed properly Yes M 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 ❑ Noa NA❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) YesEl NoN NA❑ <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA <br /> MAINTENANCE: <br /> Well/Pum visible and protected from damage Yes No ❑ NA❑ <br /> Well/Pump free from excessive vegetation lYest& INo ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes 0,1 No ❑ <br /> Permit drawing sufficient to locate well in future Yes No ❑ If'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes9 INo ❑ <br /> OTHER: <br /> Comments: <br /> Ins ected By: N R 5(66 m A 414 ED Title: �'-h/ r 15i p id <br /> Received By: Date: F/111 <br />