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SAN JOAQUIN. COUND-Y <br /> El-,JVIRONNIEI�TAL HEALTH DEPARPAIENT <br /> 1868 East Hazelton AvemUe, Stockton, CA 95205-6232 <br /> Telephone: (209)468-3420 Fax: (209)468-3433 I/ifeb:.w\l�nii.siqo,,/.orq/ehd <br /> PUMP U'48PECTION CHEC-K UST <br /> lf-,,ddress: 6 � <br /> j 11:�I c InsPe ion D 'e: <br /> 613 CAqpMay, Qj POO -38 943 <br /> 741; <br /> v Comynents/WleaSUrernents/ <br /> PararneterlStandard Mleets AJC Etandards? <br /> Recommendations <br /> c M E hIT PEDES TA L., <br /> IlDimensions of surface seal (2'x2'x4" minimum) Yes &Z I No Fj NAE] <br /> Casing extends at least 12;' above grade Yes &e No <br /> ;Casing extends at least 1" above pedestal Yes Fj INDE] I NAE] <br /> Free of ci.-acks1contiguousvvith annular seal IYes [2 1 NoEl I NAE] <br /> I Graded to allow drainage away from casing 1Yes ITI I No ❑ INA ❑ <br /> iSANITARY SEAL: it <br /> Well is sealed between pump and casing Yes INoF] NAE] <br /> Seal between all pipe columns and casing Yes [W No El NA D <br /> Sounding tube/ail-vents sealed properly IYes 0 No R NA <br /> Chlorination port available and sealed properly IYes &Z .1 No D NA El <br /> ISY-MVIPLE TAP PND BACKFLOATif PREVE1,J11-10N. li <br /> Non-thre2ded sample tap betvveen well head and <br /> ;check valve or within 3' of well head Yes F% No [] INA ❑ <br /> Adequately installed check valve or BFP device Yes No 0 1 NAE] <br /> INo cross connections (ex: chemical feeders <br /> !hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes F-1 No FI NAM <br /> Air gap of at least T (same as pipe diameter) YesEl No Fj INA W I <br /> Ftr1A I N'TE NAN G E: <br /> VVell/PUMID visible and protected from damageIY No ❑ NAE] <br /> I <br /> Well/Pump free,from excessive vegetation I Yessj E]No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well IYes No [:] <br /> -Pen-nit drawing SUfficient to locate well in future Yes I No ❑ il'nol is selected, 2ft2ch an accurate map to pen-nit <br /> -Photograph taken and attached to record `fes Lv/1 IN o El <br /> DTH IE-R: <br /> C-o nn rn e n ts. <br /> 91k I in-7 L rvryt <br /> I. <br /> 1-ispec'LedTide: <br /> 7B <br /> Received By: Date: <br /> CLA A,)r1n i9ro r <br />