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WP0039311
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4200/4300 - Liquid Waste/Water Well Permits
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WP0039311
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Last modified
9/21/2019 9:52:13 PM
Creation date
2/28/2019 8:33:43 AM
Metadata
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Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
WP0039311
PE
4382
STREET_NUMBER
2425
STREET_NAME
LUCILE
STREET_TYPE
AVE
City
STOCKTON
Zip
95209-
APN
08020002
ENTERED_DATE
2/21/2019 12:00:00 AM
SITE_LOCATION
2425 LUCILE AVE
P_LOCATION
99
P_DISTRICT
003
QC Status
Approved
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EHD - Public
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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.slAov.org/ <br /> PUMP INSPECTION CHECK LIST <br /> Address: Per t#: Inspetion Date: <br /> 1�,,c: I ZL A 1/ S�c.k Tb r�/ S`V,O O-7�7 l11112-111,- <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes�_U No ❑ INA ❑ <br /> Casing extends at least 12" above grade Yes 0 No ❑ NA ❑ <br /> Casing extends at least 1" above pedestal Yes D No ❑ NA ❑ <br /> Free of cracks/contiguous with annular seal Yes.2 No ❑ NA ❑ <br /> Graded to allow drainage away from casing Yes kZ No ❑ NA ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes No ❑ INA ❑ <br /> Seal between all pipe columns and casing Yes No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑ NA <br /> Chlorination port available and sealed properly IYes 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 No ❑ �N.A ❑ <br /> Adequately installed check valve or BFP device Yes No ❑ INA ❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No ❑ NA Ea <br /> Air gap of at least 6" (same as pipe diameter) I Yes ❑ No ❑ <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes ® No ❑ INA ❑ <br /> Well/Pump free from excessive vegetation Yes [Z INo ❑ INA ❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes © No ❑ <br /> Permit drawing sufficient to locate well in future Yes Q No ❑ If'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes No ❑ <br /> OTHER: <br /> Comments: <br /> Inspected By: Ya,,,, Title: E <br /> Received By: Date: <br /> EH-4200- 8/31/2015 <br />
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