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WP0040970
EnvironmentalHealth
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120 (STATE ROUTE 120)
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4200/4300 - Liquid Waste/Water Well Permits
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WP0040970
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Last modified
11/19/2024 4:01:50 PM
Creation date
10/19/2020 12:48:25 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
WP0040970
PE
4381
STREET_NUMBER
31447
Direction
E
STREET_NAME
STATE ROUTE 120
City
ESCALON
Zip
95320-
APN
22919016
ENTERED_DATE
7/14/2020 12:00:00 AM
SITE_LOCATION
31447 E HWY 120
P_LOCATION
99
P_DISTRICT
004
QC Status
Approved
Scanner
SJGOV\tsok
Supplemental fields
CYEAR
2020
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 • I pection Date: <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal (2'x2'x4" minimum) Yes No ❑ NA ❑ <br /> Casing extends at least 12" above grade Yes No ❑ NA ❑ <br /> Casing extends at least 1" above pedestal Yes F1 No ❑ NA ❑ <br /> Free of cracks/contiguous with annular seal Yes Pf 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 t No ❑ NA ❑ <br /> Seal between all pipe columns and casing Yes [v' No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yes R1 No ❑ NA ❑ <br /> Chlorination port available and sealed proper) Yes E' 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 L No ❑ NA ❑ <br /> Adequately installed check valve or BFP device Yes [_ No ❑ NA ❑ <br /> Any cross connections? (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ NO ❑ NA z <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 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 /> Inspected By: �I : S Lo Title: <br /> Received By: Date: ��2'7�2 P"1- ) <br /> EH-4200- 8/31/2015 <br />
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