WP0037422 - 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.si.gov.org/ehd PUMP INSPECTION CHECK LIST cu n)nn nio.1i0nar Addre s: rn Gk �J� �2PJD6-7J Permit#: WPvv3� Inspection Date: Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes No ❑ NA ❑ Casing extends at least 12" above grade Yes No ❑ NA ❑ Casing extends at least 1" above pedestal Yes Q No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes []4 No ❑ NA ❑ Graded to allow drainage away from casing Yes ❑ No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes U No ❑ INA ❑ Seal between all pipe columns and casing Yes L2 No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA Q Chlorination port available and sealed properly lYes 0 No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes ❑ No V 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 ❑✓ MAINTENANCE: Well/Pump visible and protected from damage Yes ® No ❑ NA ❑ Well/Pump free from excessive vegetation Yes [ No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes © No ❑ If ono' 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: o_t. J o Title: G VI ` 11 Ac+ Received By: Date: cu n)nn nio.1i0nar