WP0037554 - 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 Addr s•- /off rr /`'�\) G/_�/1/^ , L V ` b� _b LF, , -L'A RVI _C/- c P Per it#: wr6o.3��jb Insp ction ate: 7 �- Parameter/Standard Meets SJC Standards? Comments/Measurements/Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes g No ❑ NA ❑ Casing extends at least 12" above grade Yes U No ❑ NA ❑ Casing extends at least V above pedestal Yes No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes No ❑ NA ❑ Graded to allow drainage away from casing Yes 0 No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes No ❑ NA ❑ Seal between all pipe columns and casing Yes [2 No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA EV Chlorination port available and sealed properly Yes CA No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes KA 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 ❑ No ❑ NA 12 MAINTENANCE: Well/Pump visible and protected from damage Yes L2 No ❑ NA ❑ Well/Pump free from excessive vegetation Yes [A No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes D N'60 If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes [�d No ❑ Photograph taken and attached to record YesU No ❑ OTHER: Comments: Inspected By: ® Title: 'v,0I TVA IYUi * Received By: Date: