WP0039834 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209)468-3433 Web:www.segov.org/ehd PUMP INSPECTION CHECK LIST Address: Permit#: Ins ectio Date: 99ju en d dun R . CR Q5, 2-( q63 ie, IGI Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal 2'x2'x4" minimum Yes Z No ❑ NA ❑ Casing extends at least 12" above grade Yes [D No ❑ NA ❑ Casing extends at least 1" above pedestal Yes No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes No ❑ NA ❑ Graded to allow drainage away from casing Yes ff No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes D' No ❑ NA ❑ Seal between all pipe columns and casing Yes Z No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑ No ❑ NA Er Chlorination port available and sealed properly Yes ❑' No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non-threaded sample tap between well head and check valve or within 3' of well head Yes ✓❑� No ❑ NA ❑ Adequately installed check valve or BFP device Yes No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes ❑ No ❑ NA Air gap of at least 6" (same as pipe diameter) jYes0 No ❑ NA MAINTENANCE: Well/Pump visible and protected from damage Yes [j No ❑ NA ❑ Well/Pump free from excessive vegetation Yes Ed No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes No ❑ Permit drawing sufficient to locate well in future Yes F7f No ❑ If'no' is selected, attach an accurate map to permit Photograph taken and attached to record Yes g No ❑ OTHER: Comments: Inspected By: -�)yl�w6o Sci eitr P 1'ritle: FAA A__-. Received By: Date: EH-4200- 8/31/2015