WP0039688 - Laserfiche WebLink

Home Browse Search

- � ��,i�e �,Ic��uli� �o�>��I'�r ENVIRONMEi�lTAL HEALTH DEPARTMENT 1868 East Ha?elton Avenue, Siocl<fon, CA 95205-6232 1 Efc-��so�e: (209) 468-3420 ��ax: (209) 468-3433 int/eta; vwvvv.sjcgov.orri/ehd l�'��1P ��4�P�C`�8�a�e �9��. �E��- n fn A fnnAC Address: Permit: �� U � Inspegct�on are: � � C1,� � I' Pa€'a�}neper/s�an�a!'d [��iecis �JG stia�n�ar�s? Co3��men�sliU(eas�!reFinen'csl Rc-com;nenda:fions ---- — — � �' i�=t C= i`�€ U I='° �I� L, � T �.I.,� � � DliTlen510nS O'f 5UI IDCe seal (2'X2'X4" iTllnlmUil`]) Yes NO ❑ NA ❑ Casing extends of least 12" above grade `(es No ❑ NA ❑ Casing extends a'c least 1" above pedestal Yes No ❑ N,'� ❑ Free of cracks/contiguous �Nifh annular seal Yes No ❑ NA ❑ � � , Graded'io allow drainage away •irom casing 1'es No ❑ NA ❑ � �AI�Ia`�A�Y��A�.: Weil is sealed between pump and casing Yes No ❑ NA ❑ Seal between afl pipe columns amid casing Yes No ❑ NA ❑ � Sounding tube/aii- venfis sealed properly � Yes No ❑ NA ❑ Chlorination port available and sealed properly Yes No ❑ NA ❑ ��,I��iI='G..� "fi'A.i� �.i�� I��CI�I"'L.��iE� I�I��'��I�h��`�[�l�f� [�lon-threaded sample tap between v��ell head andl check valve or vvifhin 3' of well head 1'es ❑ No �] NA ❑ NO �' fiM � � Adeduately installed check valve or C3FP device Yes No ❑ NA ❑ No cross connections (ex: chemical feeders hooked fio disfiribu'tion systemlag flood irrigation from domestic supply) Yes ❑ No ❑ NA � Air gap of ai least 6" (same as pipe diameter) Yes ❑ No ❑ NA �I��,.fN�"�N�I`�C�a Well/Pump visible and protecfied from damage Yes ' �No ❑ NA ❑ � � Well/Pump free from e>;cessive vegefiatjon 1'es No ❑ NA ❑ i � Ci�[S�EvLI��E°�la��.U.�: i Permit drawing represents actual location of well Yes No ❑ If'no' is selected, attach an accurate ma co ermit p p i ' I Permit drawing sufficient io locafie well in future l'es Pio ❑ 1 Photograph taken and attached to record Yes No ❑ ��o[t�lz�tel�res= �� Qr`1�� ` v Y �� ' i Instaeci;ed �y: Title: �SJ` Receives By: __ Date: n fn A fnnAC