WP0037747 - 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.siaov.orq/ehd PUMP INSPECTION GHECK LIST Address*itpi W 1V 71 4 3,2 2 W6z � Pee fro p� J Inspe tion late: Parameter/Standard Comments/ its/ Meet�SJC tandards? Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes V] No ❑ INAD Casing extends at least 12" above grade Yes ® No ❑ I NA ❑ Casing extends at least 1" above pedestal Yes No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes 2 No ❑ NA ❑ Graded to allow drainage away from casing Yes No ❑ NA ❑ _ SANITARY SEAL: 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 ❑ No ❑ NAY Chlorination port available and sealed properly jYesV No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes R' No ❑ NA ❑ Adequately installed check valve or BFP device Yes a No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution systemlag flood irrigation from domestic supply) I Yes ❑ No ❑ NA Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA MAINTENANCE: Well/Pump visible and protected from damage Yes &d 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[,[� No ❑ OTHER: Comments: InspectedjE3Zj r Received By: Title: Date: EH -4200- 8/31/2015