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SR0077427
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4200/4300 - Liquid Waste/Water Well Permits
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SR0077427
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Last modified
9/19/2019 2:49:40 PM
Creation date
9/19/2019 2:03:08 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
SR0077427
PE
4380
STREET_NUMBER
20263
Direction
S
STREET_NAME
ELLIS
STREET_TYPE
RD
City
ESCALON
Zip
95320
APN
24712001
ENTERED_DATE
5/9/2017 12:00:00 AM
SITE_LOCATION
20263 S ELLIS RD
P_LOCATION
99
P_DISTRICT
004
QC Status
Approved
Scanner
TSok
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#: Ins ctio Late: <br /> ��Tio �6 Is R6f6AU) /J c)1 7 � <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes IV No ❑ NA ❑ <br /> Casing extends at least 12" above grade Yes [Z No ❑ NA ❑ <br /> Casing extends at least 1" above pedestal Yes [0 No ❑ NA ❑ <br /> Free of cracks/contiguous with annular seal Yes No ❑ NA ❑ <br /> Graded to allow drainage away from casing Yes [A No ❑ NA❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes M No ❑ NA ❑ <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 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 No ❑ NA ❑ <br /> Adequately installed check valve or BFP device Yes Q( No ❑ NA ❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No ❑ NAW <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 [;I - NOD <br /> I No ❑ NA❑ <br /> Well/Pump free from excessive vegetation Yes [,� No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes V No❑ <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: \ J" Title: <br /> Received By: bate: <br />
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