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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East HazeIton Avenue, Stockton, CA 95205-6232 <br />Tefephone: (209) 468-3420 Fax: (209) 468-3433 Web: wvvw.sigov.orgiehd <br />PUMP INSPECTION CHECK LIST • <br />P:ddress: <br />t1/4)• '1 Lk ' s.0 ' • . 'VQ L\ Ci Ck bl--V) <br />r 7—="77ermitt: <br />1% ' VCOCr <br />' Inspection Date: <br />0 SitAi( . <br />Parameter/Standard Meets SJC Standards? CommentslMeasurements/ Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x21 x4" minimum) Yes 01 No LI NA I I <br />Casing extends at least 12" above grade Yes H No NA KJI _ <br />Casing extends at least 1" above pedestal Yes HI No n NA E 1 <br />Free of cracks/contiguous with annular seal Yes gull No n NA n '• <br />Graded to allow drainage away from casing Yes 111 No I I NA LII <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes E No n NA <br />Seal between between all pipe columns and casing Yes No n NA Eli_ <br />Sounding tube/air vents Sealed properly - Yes n No NA ri <br />Chlorination port available and sealed properly Yes No I I NA I J <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 LI No NA [41 <br />Adequately installed check valve or BFP device Yes n No n NA y <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) <br />. <br />Yes 11 No Ith NA I I <br />Air gap of at least 6" (same as pipe diameter) _Yes No I I NA <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes No (1 NA n 1 <br />Well/Pump free from excessive vegetation Yes No E NA I . I i <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes Fl No LI 1 <br /> If no is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes l.\- No n <br />Photograph taken and attached to record Ye S I No -I <br />OTHER: <br />Comments: <br />\\, \L •SA.s\)'6). . <br />• <br />, . <br />' Inspected By: <br /> ‘ <br />N \ A IV Title: fOk V\ 4-/--.\ , I <br />i <br />, Received By: Date: