WP0037589 - Laserfiche WebLink

Home Browse Search

i SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone; (209) 468-3420 Fax; (209) 468-3433 Web; www.siaov.org/ehd PI IMP IAIRP1=rrT1riK1 M-IMPLI I rc'r Address: j4, jID jVC,k\j, 1 Yes ❑ No ❑ �. Penni T WY01031Sg Inspe 'o Date 2 r Parameter/Standard Meets SJC Standards? Comments/Mea uremen sl Recommendations CEMENT PEDESTAL: Non -threaded sample flap between well head and check valve or within 3' of well head Yes E] No ❑ Dimensions of surface seal (2'x2'x4" minimum) Yes No ❑ NA ❑ Casing extends at least 12" above grade Yes G1 No ❑ NA ❑ Casing extends at least 1" above pedestal Yes W No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes [0 No ❑ NA ❑ Graded to allow drainage away from casing Yes E� No ❑ NA ❑ SANITARY SEAL: Well/Pump free from excessive vegetation Yes Well is sealed between pump and casing Yes ® No ❑ NA ❑ Seal between all pipe columns and casing Yes No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ED, No ❑ NA ❑ Chlorination port available and sealed properly Yes ❑ No ❑ INA M SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample flap between well head and check valve or within 3' of well head Yes E] No ❑ NA Adequately installed check valve or BFP device Yes No ❑ NA El No cross connections (ex: chemical feeders hooked to distribution systemVag flood irrigation from domestic supply) Yes ❑ No ❑ NA Air gap of at least 6" (same as pipe diameter) Yes ❑ INoDINALZ MAINTENANCE: Well/Pump visible and protected from damage Yes La No ❑ NA ❑ Well/Pump free from excessive vegetation Yes No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes No ❑ If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes No ❑ Photograph taken and attached to record Yes [Z No ❑ OTHER: Comments: Received Bv: F-: L-1 n')nn Title: Aa /, Date: