WP0041405 - Laserfiche WebLink

Home Browse Search

SAN .IOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd PUMP INSPECTION CHECK LIST Address: Permit#: Inspection Date: Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes [� No ❑ NA ❑ Casin extends at least 12" above rade Yes [a No ❑ NA ❑ Casing extends at least 1" above pedestal Yes No ❑ NA ❑ Free of cracks/conti uous with annular seal Yes No ❑ NA ❑ Graded to allow draina a awa from casin Yes [� No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casin Yes � No ❑ NA ❑ Seal between all pipe columns and casin Yes No ❑ NA ❑ Sounding tube/air vents sealed properly Yes [� No ❑ NA ❑ Chlorination port available and sealed proper) Yes d 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 ❑ 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 sup I Yes ❑ No ❑ NA Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA [v� MAINTENANCE: Well/Pump visible and protected from dams e Yes � No ❑ NA ❑ Well/Pump free from excessive vegetation Yes No ❑ NA ❑ MISCELLANEOUS: Permit drawin represents actual location of well Yes Q` No ❑ If'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Y2S � NO ❑ Photo raph taken and attached to record Yes No ❑ OTHER: Comments: Inspected By: �,,� ", (;.,^�' �. Title: � R � Received By: Date: � � EH -4200- 8/31 /2015