WP0038347 - 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.org/ehd PUMP INSPECTION CHECK LIST Address:Per U STbc�' i X383O Ins ctio Date: Parameter/Standard Meets SJC Standards? Comments/Mea nfs/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes ® No ❑ NA ❑ Casing extends at least 12" above grade Yes [2 No ❑ NA ❑ Casing extends at least T' above pedestal Yes [2 No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes [:1 No [2 NA ElGrad C �,Cre Graded to allow drainage away from casing Yes [Z No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes ® No ❑ NA ❑ Seal between all pipe columns and casing Yes No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA ❑✓ 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 LZ No ❑ I NA ❑ Adequately installed check valve or BFP device Yes Wr No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes ❑ No ❑ NAP Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA Z MAINTENANCE: Well/Pump visible and protected from damage Yes No ❑ NA ❑ Well/Pump free from excessive vegetation Yes Wv_1 No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes Wa No ❑ If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes Wi� No ❑ Photograph taken and attached to record Yes No ❑ OTHER: Comments: ��"" n /� C (- G L ¢ Ge 11iL�� Cn ewe. Sc,�►-� a t ;, tie o Inspected By: ct-ln \ Title: r A"S.1i Jam- it Received By: Date: EH -4200- 8/31/2015