WP0040964 - 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: �(( i// [ /�, , Permit# Inspection Date: CC' CTc ICSH /�q.,�l Fig/ �� c WZ2,? L �C�p G(�� 7 7-91 Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal 2'x2'x4" minimum Yes &r No ❑ NA ❑ Casing extends at least 12" above grade Yes P' 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 No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes Q' No ❑ NA ❑ Seal between all pipe columns and casing Yes No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ❑,X No ❑ NA ❑ Chlorination port available and sealed properly Yes ❑ No ❑ NA L 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 M' No ❑ NA ❑ Any 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) Yes ❑ No ElNA ffl MAINTENANCE: Well/Pump visible and protected from damage Yes No ❑ NA ❑ Well/Pump free from excessive vegetation Yes No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes KT 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: tit Title: Received By: Date: 7 7 0 EH-4200- 8/31/2015