WP0042278 - 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.orq/ehd PUMP INSPECTION CHECK LIST Address: L�3 ZPermit#: j�,,,,S w12CC 7,Z7d' Inspection Date: 1-7-1(v- t I Parameter/Standard Meets 5JC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes No ❑ NA ❑ Casing extends at least 12" above grade Yes ❑ No NA ❑ 16-..Ir3f'`° Casing extends at least T' 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 V1 No ❑ NA ❑ Seal between all pipe columns and casing Yes No ❑ NA ❑ Sounding tube/air vents sealed properly Yes No ❑ NA ❑ Chlorination port available and sealed properly Yes 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 ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes ❑ No EK NA ❑ Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA X] MAINTENANCE: Well/Pump visible and protected from damage Yes No ❑ NA ❑ Well/Pump free from excessive vegetation Yes Ej�' No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes [v No ❑ If'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes E; ',No ❑ Photograph taken and attached to record Yes No ❑ OTHER: Comments: Inspected By: Title: Received By: Date: cu A,)nn Pm4fon4r