WP0038090 - 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.ong/ehd PUMP INSPECTION CHECK LIST Address: til �- %� �� /V L [ L Permi p Q 0 0 3 0 () 9nsp%�iion Date: 0 I l 6 / Parameter/Standard Meets SJC Standards? Comments/Measurements/ fdecommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes 9 No ❑ INA ❑ 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 © No ❑ NA ❑ Graded to allow drainage away from casing Yes [] No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes a No ❑ INA ❑ Seal between all pipe columns and casing Yes HT1 No ❑ NA ❑ Sounding tubelafr vents sealed properly Yes ❑ No ❑ NA Rf Chlorination port available and sealed properly Yes [Z No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes [Z 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) I Yes ❑ No ❑ NA ❑' Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA MAINTENANCE: Well/Pump visible and protected from damage i Yes © INo ❑ INA ❑ Well/Pump free from excessive vegetation Yes 9 INo ❑ INA ❑ MISCELLANEOUS: -- -- Permit drawing represents actual location• of well Yes 2 No ❑ if 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes 0 No ❑ Photograph taken and attached to record Yes No ❑ OTHER: _-- Comments: I �SQ1 CIA Inspected By: CAA S+J Title: ('i • f�sS/37 �•,� Received By: Date: