SR0075796 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.siclov.om/ehd PUMP INSPFr'_T1nKI r'_1a1=i'w t ICT Address:.r-, _ Parameter/Standard Permif#: Inspe tion ate o ISS 7, A l Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes ® No ❑ NA ❑ Casing extends at least 12" above grade Yes No ❑ NA ❑ Casing extends at least 1" above pedestal Yes EZ No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes [ No ❑ NA ❑ Graded to allow drainage away from casing Yes 5Z No ❑ INA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes No ❑ NA ❑ Seal between all pipe columns and casing Yes �( No ❑ NA ❑ Sounding tubefair vents sealed properly Yes ❑ No ❑ NA Chlorination port available and sealed properly Yes ❑ No ❑ NA SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample flap between well head and check valve or within 3' of well head Yes Adequately installed check valve or BFP device Yes No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) , Yes Air gap of at least 6" (same as pipe diameter) Yes MAINTENANCE: Well/Pump visible and protected from damage Yes Well/Pump free from excessive vegetation Yes MISCELLANEOUS: Permit drawing represents actual location of well Permit drawing sufficient to locate well in future Photograph taken and attached to record OTHER: Comments: Received 0-4A k N S o =u nonn 0 M No J_J NA No ❑ INA No ❑ INA No F1 INA Yes U No ❑ Yes 52 No ❑ lf'no' is selected, attach an accurate map to permit Yes V No I—f Title: Date: