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SAN JOAQUIN COUNTY <br /> .NVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 Web:www.s*gov.org/ehd <br /> WELL/PUMP SURVEY CHECK LIST <br /> Address: Program Record#: Inspection Date: <br /> Facility Name: Service Request#: Program Element: <br /> � o✓� �c�/ iv�S Z-7 ,'� <br /> Parameter/Standard Check box Meets SJC Comments/Measurements/ <br /> if inspected Standards? Recommendations <br /> Cement Pedestal: <br /> Dimensions of surface seal (2'x2'x4"minimum) ❑ YesQ No ❑ <br /> Casing extends at least 12"above grade ❑ Yes ff No ❑ <br /> Casing extends at least 1"above pedestal ❑ Yes ® No ❑ <br /> Free of cracks/contiguous with annular seal ❑ Yes © No ❑ <br /> Graded to allow drainage away from casing ❑ Yes fff No ❑ <br /> Other ❑ Yes No ❑ <br /> Sanitary Seal: <br /> Well is sealed between pump and casing ❑ Yes 9 No ❑ <br /> Sanitary seal between pipe columns and casing ❑ Yes 2L No ❑ <br /> Sounding tube/air vents sealed properly ❑ Yes Q No ❑ <br /> Chlorination port available and sealed properly ❑ Yes No ❑ <br /> Other ❑ Yes E�j- No ❑ <br /> Sampling Tap and Backflow Prevention: <br /> Non-threaded sample tap between well head and <br /> check valve or within 3'of well head ❑ Yes [�- No ❑ <br /> Adequately installed check valve(or other BFP device) ❑ Yes [a- No ❑ <br /> No cross connections(ex:chemical feeders hooked to ❑ Yes NO Eldistributions stem/a flood irrigation from domestic supply) <br /> Air gap of at least 6"(same as pipe diameter) ❑ Yes [EF No ❑ <br /> Other ❑ Yes ❑ No ❑ <br /> Other Items: <br /> Well/Pump visible and protected from damage ❑ Yes a No ❑ <br /> Well/Pump free from excessive vegetation ❑ Yes 'ff No ❑ <br /> Other ❑ Yes ❑ No ❑ <br /> Miscellaneous: <br /> Permit drawing represents actual location of well Yes ❑ No ❑ If'no'is selected,attach an accurate map to permit <br /> Permit drawing shows sufficient detail to locate well in future I Yes ❑ No ❑ <br /> Sampling Information: <br /> Sample Location: Sam le ID: <br /> Sample Date and Time: 1 Laboratory Received Date and Time: <br /> Chlorine Check - Residual Chlorine: Yes ❑ No El <br /> Analysis: otal Coliform/E. coli ❑ Nitrate ❑ DBCP ❑ Other <br /> Comments: <br /> LS <br /> Inspected By: `v &-cL /�J' ��- Title: <br /> Received By: Date: <br /> EH-4200- 4M2008 <br />