WP0037080 - 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.siclov.ora./ehd Address: PUMP INSPECTION CHECK LIST 0 N O DTT I STd Ck Td /v rmff't Pe V (� C SPfefl oD ate: Parameter/Standard No ❑ NA ❑ Meets SJC Standards? Yes CommenfslMeasurements! CEMENT PEDESTAL: Recommendafions Dimensions of surface seal 21x21x4" minimum) Yes No ❑ NA ❑ Casing extends at least 12" above grade Yes No ❑ NA ❑ Casing extends at least 1" above pedestal Yes No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes W No ❑ Nfi ❑ 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 V No ❑ NA ❑ Sounding tube�air vents sealed properly Yes ❑ No ❑ NA Chlorination port available and sealed properly Yes Q( No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample flap between well head and check valve or within 3' of well head Yes No ❑ NA ❑ 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 ❑ I No ❑ I NA MAINTENANCE: Well/Pump visible and protected from damage Yes No ❑ NA ❑ Well/Pump free from excessive vegetation Yes 9 No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes No ❑ Permit drawing sufficient to locate well in future Yes No ❑ If`no' is selected,attach an accurate map to permit Photograph taken and attached to record Yes No ❑ OTHER: Comments: Inspected By: "— O Title: En V ry nMZNq' rle Zeceived By: Date; cu AOnn