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C'OUNT' <br /> Uzi iimv j 0/�,cl u I 1\1 <br /> ENIVIRONINIENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Teferiftone:(209)468-3420 F--ax: (209)468-34330 Iffeb:vvm.slgov.org/ehd <br /> PUMP WISPECTION CHECK UST <br /> ',dd*r6ss: Perm t#': Inspection Daie: <br /> W.A&)AW,�Jcc, TeSP . C�,7, <br /> Parameted8landard Mee'LS SJC Standards? Coln <br /> ReGomrnend2'Jons <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) IYes [:1 NA I <br /> Casing extends at least 12" above grade IYes 0 NA[4 <br /> Casing extends at least 1" above pedestal IYes F1 No El NA ' I <br /> Free of Cj-aC1<SjCC)nflgUOUS VAth afflllUlal- Seal _+,,,I"e El No El NA <br /> Yes <br /> Graded to allow drainageaway from casing es El No [:1 NA <br /> SMOTARY SEAL: <br /> Well is sealed between pump and Casing Yes [I No ❑ NA <br /> Seal between all pipe columns and casing <br /> Yes El I No wi' INA El <br /> Sounding tome/air vents sealed properly YesEl I No 0 INA [41 1 <br /> Chlorination pork available and sealed properly Yes E INoE1 I PIA[Sj I <br /> ISAMPLE *FAP AND BikCKFLOV'v'PREVENTION: <br /> Non-threaded sample tap between vvell head and <br /> check valve or within 'D' of well head �.Yes ❑ No 0 NA <br /> Adequately installed check valve or CFP device I Y.cisEl 1`10 1-1 NA <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> I <br /> TI orn domiestic.supply) Yes [:] No 41 NA❑ <br /> Air cap of at least 67' (same as pipe diameter) I Yes ❑ INoD NAJI <br /> MAINTENANCE. <br /> N'VelliPump visible and protected from damage Yes No ❑ INA <br /> -Well/Pump free from excessive vegetation Yes No D I NA 1:1 <br /> 4 <br /> 1.101 1,1-1'C E LLAN EO U S. <br /> Permit drawing represents actual locationofvvell Yes INoE1 <br /> Permit dravving SLIfficient'Lo locate well in fui-ure Yes I No [:1 If'no'is selectcd,attach an accurate map to perr-nit <br /> Um <br /> Photograph taken and attached to record y es LINoD <br /> OT 1-1 E R: <br /> C-0 In n-1 c-1-1 ts: <br /> L kK'\ <br /> 4A �A <br /> Vi <br /> ti <br /> Inspected BY: <br /> I; <br /> 11 Received By: Date. <br />