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WP0039024
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4200/4300 - Liquid Waste/Water Well Permits
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WP0039024
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Last modified
4/17/2019 12:06:39 PM
Creation date
4/17/2019 11:08:20 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
WP0039024
PE
4382
STREET_NUMBER
8900
Direction
N
STREET_NAME
CANEPA
STREET_TYPE
RD
City
STOCKTON
Zip
95212-
APN
08643027
ENTERED_DATE
11/13/2018 12:00:00 AM
SITE_LOCATION
8900 N CANEPA RD
P_LOCATION
99
P_DISTRICT
004
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: wvvw.si-gov.org/ehd <br />PUMP INSPECTION CHECK LIST <br />Address: <br />9�N M 4_1 1�% oLt--,o).j `kS ZI'L <br />Permit#: <br />wQ pTj 1"A <br />Inspection Date: <br />I W 15IIPO <br />Parameter/Standard <br />Meets SJC Standards? <br />Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal 2'x2'x4" minimum) <br />Yes Ed <br />No ❑ <br />NA ❑ <br />Casing extends at least 12" above grade <br />Yes 14 <br />No ❑ <br />NA ❑ <br />Casing extends at least 1" above pedestal <br />Yes <br />No ❑ <br />NA ❑ <br />Free of cracks/contiguous with annular seal <br />Yes Ej <br />No ❑ <br />NA' ❑ <br />Graded to allow drainage.away from casing <br />Yes <br />No ❑ <br />NA ❑ <br />SANITARY SEAL: <br />Well is sealed between pump and casing <br />Yes <br />No ❑ <br />NA ❑ <br />Seal between all pipe columns and casing <br />Yes [ <br />No ❑ <br />NA ❑ <br />Sounding tube/air vents sealed properly <br />Yes <br />No ❑ <br />NA ❑ <br />Chlorination port available and sealed properly <br />YesE4 <br />No ❑ <br />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 <br />Yes <br />No ❑ <br />NA ❑ <br />Adequately installed check valve or BFP device <br />Yes <br />No ❑ <br />NA ❑ <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) <br />Yes 14 <br />No ❑ <br />NA ❑ <br />Air gap of at least 6" (same as pipe diameter) <br />Yes ❑ <br />No ❑ <br />NA <br />MAINTENANCE: <br />Well/Pump visible and protected from damage <br />Yes <br />No ❑ <br />NA ❑ <br />Well/Pump free from excessive vegetation <br />Yes Q <br />No ❑ <br />NA ❑ <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well <br />Yes <br />No ❑ <br />if 'no' is selected, attach an accurate map to permit <br />Permit drawing sufficient to locate well in future <br />Yes <br />No ❑ <br />Photograph taken and attached to record <br />YesEj <br />No ❑ <br />OTHER: <br />Comments: <br />Inspected By: <br />Title: ih <br />Received By: Date: <br />
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