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� SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 186.8_EastHazelton-Amenue,_S_t-o-cktQD., CA 95205-6232 - <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.om/ehd <br /> PUMP MSPECTION GREGKTIST - ---- - <br /> Address: Permitil; Inspection Date: <br /> Parameter/Standard Meets SJC Standards? Commentsl easrlrementsl <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes[2 No ❑ NA❑ _ <br /> Casing extends at least 12"above grade Yes U No ❑ NA❑ <br /> Casing extends at least V above pedestal Yes No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes 0 No ❑ NA❑ <br /> Graded to allow drainage away from casing YesC I No ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes No ❑ NA❑ <br /> Seal between all pipe columns and casing Yes No ❑ NA❑ <br /> Sounding tube/air vents sealed properly - Yes ❑ No ❑ NA[� <br /> Chlorination port available and sealed properly Yes W No ❑ NA❑ <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 W No❑ NA❑ <br /> Adequately installed check valve or BFP device Yes V No ❑ NA❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No ❑ NA[V <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NAV <br /> MAINTENANCE: <br /> Well/Pump visible and rotected from damage Yes S _N o ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes [A No ❑ NA❑ <br /> MISCELLANEOUS: . <br /> Permit drawing represents actual location of well .Yes Q No ❑ <br /> Permit drawing sufficient to locate well in future Yes No ❑ If'no'is selected,attach an accurate map to permit <br /> Photogra h taken and attached to record Yes No ❑ <br /> OTHER: <br /> Comments: a <br /> Inspected By: GZh S'0Title: V n/►�u.-1�� �� r <br /> Received By: Date: <br /> nfnA lnnAC <br />