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WP0038206
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4200/4300 - Liquid Waste/Water Well Permits
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WP0038206
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Last modified
1/23/2019 11:36:59 AM
Creation date
1/23/2019 10:37:45 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
WP0038206
PE
4381
STREET_NUMBER
10100
Direction
N
STREET_NAME
DAVIS
STREET_TYPE
RD
City
STOCKTON
Zip
95209-
APN
07014007
ENTERED_DATE
5/1/2018 12:00:00 AM
SITE_LOCATION
10100 N DAVIS RD
P_LOCATION
99
P_DISTRICT
003
QC Status
Approved
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DAfonskaia
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EHD - Public
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S ' <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Fax: (209)468-3433 Web:www.sigov.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Per i : tnspe tion ate: <br /> 0100 St� a(b �' on38ac�-6 0510 <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal 2'x2'x4" minimum) Yes ❑ No ❑ NA ❑ _ <br /> Casing extends at least 12" above grade Yes ❑ No ❑ NA❑ e � Co-.Crttc <br /> Casing extends at least 1" above pedestal Yes ❑ No ❑ NA ❑ <br /> Free of cracks/contiguous with annular seal Yes ❑ No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes ❑ No ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes 0 No ❑ NA❑ <br /> Seal between all pipe columns and casing Yes W1 No ❑ NA❑ <br /> Sounding tube/ai.r vents sealed properly Yes ❑ No ❑ NA[2 <br /> Chlorination port available and sealed properly Yes 0 No ❑ 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 Yes R No ❑ NA ❑ <br /> Adequately installed check valve or BFP device Yes U No ❑ NA ❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No ❑ NA [ <br /> Air gap of at least 6" (same as pipe diameter) IYes ❑ No ❑ NA <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage IYes U I No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes F/[ I No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well IYes INo ❑ <br /> Permit drawing sufficient to locate well in future Yes 1 No ❑ if'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record IYes 0 INo ❑ <br /> OTHER: <br /> Comments: <br /> Inspected By: (.t.� Title: LJ <br /> Received By: Date: <br /> EH-4200- 8131/2015 <br />
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