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, SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone;(209)468-3420 Fait: (209)468-3433 Web;www.sigov.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address; //��" � Permit#: !ns ecfyon Da ; <br /> J Li l,l.t IAV Q Get-� �'U ��Z 6 P o <br /> Parameter/Standard Meets SJC Standards? Comments/Measurementsl <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes ❑ WoN <br /> Casing extends at least '12" above grade Yes ❑Casing extends at least 1" above pedestal Yes ❑Free ofcracks/contiguous with annular seal Yes ❑Graded to allow drainage away from casing Yes ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing IYes ❑ NoL <br /> ❑ <br /> Seal between all pipe columns and casing Yes <br /> El ❑ <br /> Sounding tubelair vents sealed properly Yes El ❑Chlorination port available and sealed properly Yes El ❑ <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 ❑ INo❑ NA07 <br /> Adequately installed check valve or BFP device I Yes ❑ I No ❑ NA❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ I No❑ NA❑ <br /> Air gap of at least 6" (same as pipe diameter) IYes ❑ jNoo NA❑ <br /> MAINTENANCE: -- <br /> Well/Pump visible and protected from damage Yes ❑ No ❑ NA❑ <br /> '/Vell/Pump free from excessive vegetation Yes❑ 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 ❑ lf`no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes ❑ No❑ <br /> OTHER: <br /> Comments: <br /> I �a��- � TL C- 'IY q,_,� "POr. i I <br /> 1j (k `�, rJL1 6 f D 6 - A A c M - -l..Jz- f U,1'hP !,/4 J <br /> r r d ) <br /> Inspected By: GUS -S� Title: 11 G�1 VI Fv h / i' <br /> Received By: Date: <br /> cu A)nn <br />