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WP0038335
EnvironmentalHealth
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EMERSON
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4200/4300 - Liquid Waste/Water Well Permits
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WP0038335
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Entry Properties
Last modified
6/10/2019 12:24:31 PM
Creation date
5/24/2019 3:30:46 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
WP0038335
PE
4380
STREET_NUMBER
3876
Direction
E
STREET_NAME
EMERSON
STREET_TYPE
RD
City
ACAMPO
Zip
95220-
APN
00514523
ENTERED_DATE
5/25/2018 12:00:00 AM
SITE_LOCATION
3876 E EMERSON RD
P_LOCATION
99
P_DISTRICT
004
QC Status
Approved
Scanner
AGooderham
Tags
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.sigov.org/ehd <br /> PUMP INSPECTION CHECK LIST <br /> Address: Permit-`.�: —`___. Inspection Date: <br /> \ca12D I w pO3 3 5 i!_ I <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements) <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) YesNo ❑ NA❑ <br /> Casing extends at least 12" above grade Yes 3 No ❑ NA❑ <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 No ❑ INA ❑ <br /> I <br /> Seal between all pipe columns and casing YesNo F1 INA [ISounding tube/air vents sealed properly Yes No F-1NA El <br /> Chlorination port available and sealed properly Yes 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 F� I No NA ❑ <br /> Adequately installed check valve or BFP device Yes ❑ No Ej NA ❑ rr K-E � f L <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes d No ❑ NA ❑ <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well IYes INo ❑ <br /> Permit drawing sufficient to locate well in future Yes 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: Title: <br /> Received By: Date: <br />
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