Laserfiche WebLink
, R <br />SAN JOAQUIN GoUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.orq/ehd <br />PUMP INSPECTION CHECK LIST <br />Address. Permit#: Inspe5iion Date: <br />1141 3 S a rrn �� t 9 Seal S'�lo 0'7 a 1,,3 . /[[� <br />0 <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) <br />Yes No ❑ NA <br />Casing extends at least 12" above grade <br />Yes ® No ❑ NA <br />Casing extends at least 1" above pedestal <br />Yes ® No ❑ NA <br />Free of cracks/contiguous with annular seal <br />Yes No ❑ NA <br />Graded to allow drainage away from casing <br />Yes 9 JNoE1 INA <br />SANITARY SEAL: <br />Well is sealed between pump and casing <br />Yes ` No 0 NA; <br />Seal between all pipe columns and casing <br />IYes 2 No ❑ NA � <br />Sounding tubelair vents sealed properly <br />Yes ❑ No ❑ NA 1 <br />Chlorination port available and sealed properly <br />Yes LUZ No ❑ NA [ <br />SAMPLE TAP AND BACKFLOW PREVENTION: <br />Non -threaded sample tap between well head and <br />check valve or within 3' of well head Yes ❑ No NA r <br />Adequately installed check valve or BFP device <br />Yes No ❑ NA [ <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) <br />Yes ❑ No ❑ NA <br />Air gap of at least 6" (same as pipe diameter) <br />Yes ❑ No ❑ NA <br />MAINTENANCE: <br />WelUPump visible and protected from damage1YesiKj <br />Yes No ❑ NAE <br />WeII/Pump free from excessive vegetation <br />No ❑ NA <br />MISGELLANEOUS: <br />Permit drawing represents actual location of well <br />YesiQ <br />No [ <br />Permit drawing sufficient to locate well in future <br />Yes 0 <br />No [ <br />Photograph taken and attached to record <br />Yes LE <br />No [ <br />OTHER: <br />If'no' is selected, attach an accurate map to permit <br />strs�-a,,,�— <br />Inspected By: f Qom► I 1-.J S v <br />Tule: <br />Received By: Date: <br />Gu A-0nn <br />u <br />