WP0041506 - 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.or /q ehd PUMP INSPECTION CHECK LIST Address: ) / Permit#: Inspection Date: L eC%r mil' t C ., �. t l c: t-` t t / C ( 2/7,14— Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes 0� No ❑ NA ❑ Casing extends at least 12" above grade Yes 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 EZNo ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes No ❑ NA ❑ Seal between all pipe columns and casing Yes D No ❑ NA ❑ Sounding tube/air vents sealed properly Yes No ❑ NA ❑ Chlorination port available and sealed properly YesE2r ,No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non-threaded sample tap between well head and check valve or within 3' of well head Yes 2 No ❑ NA ❑ Adequately installed check valve or BFP device Yes 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 ❑ NA MAINTENANCE: Well/Pump visible and protected from damage Yes No ❑ NA ❑ Well/Pump free from excessive ve etation Yes No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes Q No ❑ Permit drawing sufficient to locate well in future Yes ff No ❑ If'no' is selected, attach an accurate map to permit Photograph taken and attached to record Yes Vr No ❑ OTHER: Comments: Inspected By: C 'e- k"2 Title: Received By: Date: EH-4200- 8/31/2015