WP0037178 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 186.8_East_Hazelton_Av-enue,-atQcktQn, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.slgoy.orq/ehd PUMP 1N5PE__C_ T01WGflEGK U_ST- Address:Perms 1 srACA IO RE A �Utf4 0 • �1 0037 OF Inspectio Date: 1613/21 . ParameterlStandard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes 2 No ❑ NA ❑ Casing extends at least 12" above grade Yes No ❑ NA ❑ Casing extends at least V above pedestal Yes No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes 2 No ❑ NA ❑ Graded to allow drainage away from casing Yes W No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes S2 - No ❑ NA ❑ Seal between all pipe columns and casing Yes M No ❑ NA ❑ Sounding tube/air vents sealed properly - Yes ❑ No ❑ NA [Y 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 V No ❑ NA ❑ Adequately installed check valve or BFP device Yes V No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes ❑ No ❑ NA V Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA [V MAINTENANCE: Well/Pump visible and protected from damage Yes V No ❑ NA ❑ Well/Pump free from excessive vegetation Yes No ❑ NA El MISCELLANEOUS:,- ISCELLANEOUS:.Permit Permitdrawing 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: Inspected By: " �'U Title: Ij n jQ w ht A4. Received By: Date: n1 -1n 4C