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• SAN jOAQUINI COUNTY <br /> ENIVIRONIMENTAL HEALTH DEPARTMENT <br /> 1868 East HazeltOii Avenue, Stockton, CA 95205-6232 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 Vileb:vv\ivw.sigov.org/ehd <br /> PUMP IINSPECTIONI GF;ECK UST <br /> hi-Address Permitt.: InIspetion Date: <br /> P AcAmPO <br /> A,52-7S Pu "o)A-0 kv IZOO-16Y jD 9 /z, 6 <br /> Parameter/Standard Mee-ts AJC Standards? Comm'entslMe, wrients/ <br /> I' Recornmendations-- <br /> CEMEKIT' PEDESTAL: <br /> Dimensions of surface seal (21x2'x4" minimum) Yes FA No ❑ NA❑ <br /> Casing extends at least 12;' above grade Yes L2 No ❑ NA❑ r <br /> Casing extends at least 1" above pedestal Yes L–cl No ❑ NAE] <br /> Free of cracks/contiguous with annular seal Yes 2 No NAII <br /> 'Graded to allow drainage away fi-oni casing Yes P� NoEl NA 0 <br /> PANITARY SEAL: <br /> Well is sealed between PUMID and casing Yes E;' No R NA❑ <br /> Seal between all 1:)ilDe columns and casing Yes No El NA [:1 <br /> ;Sounding tube/air vents sealed properly Yes Wr No [] NA ❑ <br /> Chlorination port available and sealed properly Yes V NoEl NA [-I <br /> SAMPLE TAP AND BACKFLOW PREVENTION: <br /> Non-threaded sample tap b I etween well head and <br /> check valve or within 3' of well head Yes 9 lNo El INA 0 <br /> Adequately installed check valve or BFP device Yes 9 No [—I INAE] <br /> IN o cross connections (ex: chemical feeders <br /> !hooked to distribution systern/ag flood irrigation <br /> I <br /> r- ni <br /> i i odornestic supply) YesEj NoF❑-1 NAP <br /> jo <br /> iAir gap of at least 6" (same as pipe diameter) Yes E] <br /> 0 No D ,NA Vr <br /> IMAINTENANCE: <br /> (Well/Pump visible and protected from damage Yes No F-1 I NAE] <br /> (Well/Pump free from excessive vegetation Yes Vr NoEl INAE] I <br /> IMUSGELLANEOUS: <br /> I <br /> Permit drawing represents actual location of well Yes No ❑ <br /> I Permit drawing sufficient to locate well in future Yes F2 I NoEj 1f'n,'isselected,=-LLach an accurate map to perms <br /> Photograph taken and attached to record Yes F/I No F1 <br /> OTHER: <br /> Comments, i <br /> inspected By: e: <br /> Received By: Date: <br /> F-W A^rlrl <br />