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4200/4300 - Liquid Waste/Water Well Permits
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WP0040307
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Last modified
1/29/2020 2:15:42 PM
Creation date
1/29/2020 1:23:14 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
WP0040307
PE
4381
STREET_NUMBER
1040
STREET_NAME
WILLORA
STREET_TYPE
RD
City
STOCKTON
Zip
95207-
APN
07736033
ENTERED_DATE
11/15/2019 12:00:00 AM
SITE_LOCATION
1040 WILLORA RD
P_LOCATION
01
P_DISTRICT
002
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#: Inspection Date: <br /> IcAu Mi c GI W U4 -1- 1211 a In <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" rninirnum) Yes [1 No ❑ NA ❑ <br /> Casing extends at least 12" above grade Yes [Z No ❑ NA ❑ <br /> Casing extends at least 1" above pedestal Yes W No ❑ NA ❑ <br /> Free of cracks/contiguous with annular seal Yes [0 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 kZ No ❑ NA ❑ <br /> Seal between all pipe columns and casing Yes [� No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yes V No ❑ NA ❑ <br /> Chlorination port available and sealed proper) Yes E�K 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 ONA ❑ <br /> Adequately installed check valve or BFP device Yes [r No ❑ NA ❑ <br /> Any cross connections? (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> frorn domestic supply) Yes ❑ No ❑ NA Rr <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA [j <br /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes 0' No ❑ NA ❑ <br /> Well/Pump free frorn excessive vegetation Yes []� No ❑ NA ❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes 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 /> �'JL� sOwnoe .too <br /> Inspected By: -}eY-n Title: Elk �- <br /> Received By: Date: <br /> EH-4200- 8/31/2015 <br />
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