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4200/4300 - Liquid Waste/Water Well Permits
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WP0038440
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Entry Properties
Last modified
9/10/2018 2:53:09 PM
Creation date
9/10/2018 2:47:43 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
WP0038440
PE
4381
STREET_NUMBER
31700
Direction
S
STREET_NAME
BIRD
STREET_TYPE
RD
City
TRACY
Zip
95304-
APN
25505027
ENTERED_DATE
6/18/2018 12:00:00 AM
SITE_LOCATION
31700 S BIRD RD
P_LOCATION
99
P_DISTRICT
005
QC Status
Approved
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EHD - Public
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SAN JOAQUIN COUNTY <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:Per <br />0 0 �S- 1 —i <br />#: <br />c„ ro 0 38 4qQ <br />Inspe tion Date: <br />06 <br />Parameter/Standard <br />Meets SJC Standards? <br />Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) <br />Yes [j <br />No ❑ <br />INA ❑ <br />Casing extends at least 12" above grade <br />Yes © <br />No ❑ <br />NA ❑ <br />Casing extends at least 1" above pedestal <br />Yes [2 <br />No ❑ <br />NA ❑ <br />Free of cracks/contiguous with annular seal <br />Yes <br />No ❑ <br />NA ❑ <br />Graded to allow drainage away from casing <br />Yes <br />No ❑ <br />NA ❑ <br />SANITARY SEAL: <br />Well is sealed between pump and casing <br />Yes <br />No ❑ <br />NA ❑ <br />Seal between all pipe columns and casing <br />Yes <br />No ❑ <br />NA ❑ <br />Sounding tube/air vents sealed properly <br />Yes ❑ <br />No ❑ <br />NA <br />Chlorination port available and sealed properly <br />Yes2 <br />No ❑ <br />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 <br />Yes [� <br />No ❑ <br />P� <br />NA <br />Adequately installed check valve or BFP device <br />Yes Q <br />No ❑ <br />NA ❑ <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) <br />Yes ❑ <br />No ❑ <br />NA EV <br />Air gap of at least 6" (same as pipe diameter) <br />Yes ❑ <br />No ❑ <br />NA 0 <br />MAINTENANCE: <br />Well/Pump visible and protected from damage <br />Yes <br />No ❑ <br />NA ❑ <br />Well/Pump free from excessive vegetation <br />Yes <br />No ❑ <br />NA ❑ <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well <br />Yes 52 <br />No ❑ <br />if'no' is selected, attach an accurate map to permit <br />Permit drawing sufficient to locate well in future <br />Yes <br />No ❑ <br />Photograph taken and attached to record <br />Yes <br />No ❑ <br />OTHER: <br />Comments:/ <br />Inspected By: Y CIA, <br />Title: C-' d <br />Received By: <br />Date: <br />CIA n)nn <br />Qlvafor) a� <br />
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