WP0042148 - Laserfiche WebLink

Home Browse Search

SAN aJOAQUIN 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: cj A 4l 1r•ix,. c Au h>h>L k l 0" Permit#: oa 4.1 I Ak q Inspection Date: i I. ). I Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes No ❑ NA ❑ Casing extends at least 12" above grade YesZF No ❑ NA ❑ Casing extends at least 1" above pedestal YnEj No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes ❑ No NA ❑ Graded to allow drainage away from casing Yesgo No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Ye_%Pj No ❑ NA ❑ Seal between all pipe columns and casing YeqZ No ❑ NA ❑ Sounding tube/air vents sealed properly Ye No ❑ NA ❑ Chlorination port available and sealed proper) Ye 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 Yeso No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply I Yes(, No ❑ INA.[:] Air gap of at least 6" (same as pipe diameter) Yesl ❑ No ❑ NA MAINTENANCE: Well/Pump visible and protected from damage Yes No ❑ NA ❑ Well/Pump free from excessive vegetation Ye No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well YeoEf No ❑ If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Ye Photograph taken and attached to record YesO No ❑ OTHER: Comments: Inspected By: ✓�� - �y `t Title: Received By: n Date: ( e ` 1 d EH -4200- 8/31/2015