WP0037311 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1.86.8 -East Hazelto -Avenue, S±Qr,-kto_u, CA 95205-6232 _ Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.orq/ehd P PIP INSP_ECfiF0WZFIE-CK11ST Address: n IYI ;P.s E /_� t Permit#:Inspeotion 'tel L-0 0 > 3 ! ate: �r ParameterlStandard 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 [,a No ❑ NA ❑ Casing extends at least V above pedestal Yes No ❑ NA ❑ Free of crackslcontiguous with annular seal Yes No ❑ NA ❑ Graded to allow drainage away from casing IYesjNoE1 NA ❑ SANITARY SEAL: Well is sealed between. pump and casing Yes - No ❑ NA ❑ Seal between all pipe columns and casing Yes [0 No ❑ NA ❑ Sounding tube/air vents sealed properly - Yes ❑ No ❑ NA Chlorination port available and sealed properly Yes No ❑ NA ❑ TAP AND BACKFLOW PREVENTION: _SAMPLE Non -threaded sample tap between well head and check valve or within 3' of well head Yes M No ❑ NA ❑ Adequately installed check valve or BFP device Yes No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes ❑ No ❑ NA Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA [V MAINTENANCE- Well/Pump visible and protected from damage Yes [0 No ❑ NA ❑ Well/Pump free from excessive vegetation Yes No ❑ NA MISCELLANEOUS: . Permit drawing represents actual location of well . Yes a No ❑ if 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes EA No ❑ Photograph taken and attached to record Yebv No ❑ OTHER: Comments: Inspected Bv: \ / ov, l I v S o ITitle: *_Ci jl� A" Received Date: n1 1-4