WP0040255 - 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.sigov.org/ehd PUMP INSPECTION CHECK LIST Address: Permit#: Inspection Date: 2 d 6,6 5kCoC' Q►h�\-1 VV �tU' F-3 12 / Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes [✓]� No ❑ NA ❑ Casing extends at least 12" above grade Yes No ❑ NA ❑ Casing extends at least 1" above pedestal Yes 0' No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes [Z 1No ❑ NA ❑ Graded to allow drainage away from casing Yes Z No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes [Z No ❑ NA ❑ Seal between all pipe columns and casing Yes E�f' No ❑ NA ❑ Sounding tube/air vents sealed properly Yes 2' No ❑ NA ❑ 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 d Adequately installed check valve or BFP device Yes ❑ No ❑ NA ❑ Any cross connections? (ex: chemical feeders hooked to distribution system/ag flood irrigation frorn domestic supply) Yes ❑ No ❑ NA [/ Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA ❑ MAINTENANCE: Well/Pump visible and protected from damage Yes [✓7 No ❑ NA ❑ Well/Pump free from excessive vegetation Yes []� No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes [;?f No ❑ Permit drawing sufficient to locate well in future Yes No ❑ If'no'is selected, attach an accurate map to permit Photograph taken and attached to record Yes No ❑ OTHER: Comments: Inspected By: Title: Received By: Date: EH-4200- 8/31/2015