WP0038456 - 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 Address: A� `� q ��l I �1 C i 0 n!� R� l— Per i I cD 3� Inspection ate: C, 7/0 3Ile 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 Z No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes ® 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 [j INA ElSounding tube/air vents sealed properly Yes V No ❑ NA ❑ Chlorination port available and sealed properly Yes ❑ No ❑ NA SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes ❑ No ❑ NA Q — 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 ❑ NAW MAINTENANCE: Well/Pump visible and protected from damage Yes Q No ❑ NA ❑ Well/Pump free from excessive vegetation Yes Wr 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: - i Inspected By: Gly Title:' �S.tlJ Received By: Date: MU A Inn aiI:kq rOna G