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SAN aIOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.orq/ehd <br />PUMP INSPECTION CHECK LIST <br />Address: �,�� � <br />J � O r� �-.�� <br />�� <br />C� �ts'2 <br />Z-� <br />Permit#: <br />lti' �P 0 0 � °I <br />Inspection Date: <br />° vL � <br />Parameter/Standard <br />Meets SJC <br />Standards? <br />Comments/Measurements <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) <br />Yes <br />No <br />❑ <br />NA <br />❑ <br />Casin extends at least 12" above rade <br />Yes <br />[jam <br />No <br />❑ <br />NA <br />❑ <br />Casing extends at least 1" above pedestal <br />Yes <br />� <br />No <br />❑ <br />NA <br />❑ <br />Free of cracks/conti uous with annular seal <br />Yes <br />[� <br />No <br />❑ <br />NA <br />❑ <br />Graded to allow draina a awa from casin <br />Yes <br />No <br />❑ <br />NA <br />❑ <br />SANITARY SEAL: <br />Well is sealed between pump and casin <br />Yes <br />[.� <br />No <br />❑ <br />NA <br />❑ <br />Seal between all pipe columns and casin <br />Yes <br />� <br />No <br />❑ <br />NA <br />❑ <br />Sounding tube/air vents sealed properly <br />Yes <br />� <br />No <br />❑ <br />NA <br />❑ <br />Chlorination port available and sealed proper) <br />Yes <br />No <br />❑ <br />NA <br />❑ <br />SAMPLE TAP AND BACKFLOW PREVENTION: <br />Non -threaded sample tap between well head and <br />check valve or within 3' of well head <br />Yes <br />'✓� <br />No <br />❑ <br />NA <br />❑ <br />Adequately installed check valve or BFP device <br />Yes <br />/� <br />No <br />❑ <br />NA <br />❑ <br />Any cross connections? (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic sup I <br />Yes <br />❑ <br />No <br />❑ <br />NA <br />[� <br />Air gap of at least 6" (same as pipe diameter) <br />Yes <br />❑ <br />No <br />❑ <br />NA <br />[i� <br />MAINTENANCE: <br />Well/Pump visible and protected from dams e <br />Yes <br />►� <br />No <br />❑ <br />NA <br />❑ <br />Well/Pump free from excessive vegetation <br />Yes <br />[17f <br />No <br />❑ <br />NA <br />❑ <br />MISCELLANEOUS: <br />Permit drawin represents actual location of well <br />Yes <br />� <br />No <br />❑ <br />If'no' is selected, attach an accurate map to permit <br />Permit drawing sufficient to locate well in future <br />YeS <br />NO <br />❑ <br />Photo raph taken and attached to record <br />Yes <br />- <br />No <br />❑ <br />OTHER: <br />Comments: <br />Inspected By: �,� ` .o , ; � `� <br />Title: �f .� S ' �r r� <br />Received By: <br />Date: , ' R ��21 <br />EH -4200- 8/31/2015 <br />