WP0037628 - 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.sigov.orq/ehd PUMP INSPECTION CHECK LIST Add�rei's f i� ( 4l I �1 �� S 1 D C 1� Ib /) Permi � �tj /p FInsp ;2�G��f'p e: Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes [Z No ❑ NA ❑ Casing extends at least 12" above grade Yes © No ❑ NA ❑ Casing extends at least 1" above pedestal Yes [0 No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes Q No ❑ NA ❑ Graded to allow drainage away from casing Yes [?I No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes Q No ❑ NA ❑ Seal between all pipe columns and casing Yes E2 No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA [� Chlorination port available and sealed properly IYes 0 No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes P� No ❑ NA [ff 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 FZ MAINTENANCE: Well/Pump visible and protected from damage Yes 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 Q No ❑ Photograph taken and attached to record Yes Zj No ❑ OTHER: Comments: Inspected 0 r, ASS/J t` Title: Received By: Date: cu n')nn o1,24innac