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A <br />I <br />SAN JOAQUIN 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.oro/ehd <br />PUMP INSPECTION CHECK LIST <br />— I Permit#. <br />Parameter/Standard Meets SJC Standards? <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) <br />Yes <br />Casing extends at least 12" above grade <br />IYes <br />Casing extends at least 1" above pedestalYes <br />Free of cracks/contiguous with annular seal <br />Yes <br />Graded to allow drainage away from casing <br />Yes <br />SANITARY SEAL: <br />Well is sealed between pump and casing :4Yes <br />Seal between all pipe columns and casing <br />Yes <br />Sounding tubefair vents sealed properly <br />Yes <br />Chlorination port available and sealed properly <br />Yes 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 j <br />Adequately installed check valve or BFP device <br />Yes <br />No cross connections (ex: chemical feeders <br />hooked to distribution systemlag flood irrigation <br />from domestic supply) <br />Yes [ <br />Air gap of at least 6"same as pipe diameter) <br />Yes [ <br />MAINTENANCE: <br />Well/Pump visible and protected from damageYes <br />Well/Pump free from excessive vegetation <br />Yes [( <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well <br />Permit drawing sufficient to locate well in future <br />Photograph taken and attached to record <br />OTHER: <br />ICommenis: <br />No <br />No <br />No <br />No <br />No <br />No J_] INA <br />No ❑ INA <br />No ❑ NA <br />No ❑ NA <br />Yes <br />Yes <br />Yes <br />No <br />No <br />No <br />V1--5 /13Z) I1o(1-0- <br />Comments/Measurements/ <br />Recommendations <br />If'no' is selected, attach an accurate map to permit <br />,ns pect�11y. ZeceiveDate: <br />E:" n -)nn <br />Date: <br />