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WP0037178
EnvironmentalHealth
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MCINTIRE
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4200/4300 - Liquid Waste/Water Well Permits
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WP0037178
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Entry Properties
Last modified
9/20/2018 9:33:15 AM
Creation date
9/20/2018 9:13:46 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
WP0037178
PE
4381
STREET_NUMBER
24188
Direction
N
STREET_NAME
MCINTIRE
STREET_TYPE
RD
City
CLEMENTS
Zip
95227-
APN
02313010
ENTERED_DATE
8/28/2017 12:00:00 AM
SITE_LOCATION
24188 N MCINTIRE RD
P_LOCATION
99
P_DISTRICT
004
QC Status
Approved
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DAfonskaia
Tags
EHD - Public
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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />186.8_East_Hazelton_Av-enue,-atQcktQn, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.slgoy.orq/ehd <br />PUMP 1N5PE__C_ T01WGflEGK U_ST- <br />Address:Perms <br />1 srACA IO RE A �Utf4 0 <br />• <br />�1 0037 OF <br />Inspectio Date: <br />1613/21 . <br />ParameterlStandard <br />Meets SJC Standards? <br />Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) <br />Yes 2 <br />No ❑ <br />NA ❑ <br />Casing extends at least 12" above grade <br />Yes <br />No ❑ <br />NA ❑ <br />Casing extends at least V above pedestal <br />Yes <br />No ❑ <br />NA ❑ <br />Free of cracks/contiguous with annular seal <br />Yes 2 <br />No ❑ <br />NA ❑ <br />Graded to allow drainage away from casing <br />Yes W <br />No ❑ <br />NA ❑ <br />SANITARY SEAL: <br />Well is sealed between pump and casing <br />Yes S2 - <br />No ❑ <br />NA ❑ <br />Seal between all pipe columns and casing <br />Yes M <br />No ❑ <br />NA ❑ <br />Sounding tube/air vents sealed properly - <br />Yes ❑ <br />No ❑ <br />NA [Y <br />Chlorination port available and sealed properly <br />Yes <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 V <br />No ❑ <br />NA ❑ <br />Adequately installed check valve or BFP device <br />Yes V <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 V <br />Air gap of at least 6" (same as pipe diameter) <br />Yes ❑ <br />No ❑ <br />NA [V <br />MAINTENANCE: <br />Well/Pump visible and protected from damage <br />Yes V <br />No ❑ <br />NA ❑ <br />Well/Pump free from excessive vegetation <br />Yes <br />No ❑ <br />NA El <br />MISCELLANEOUS:,- <br />ISCELLANEOUS:.Permit <br />Permitdrawing represents actual location of well . <br />Yes <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: " �'U <br />Title: Ij n jQ w ht A4. <br />Received By: <br />Date: <br />n1 -1n 4C <br />
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