WP0041972 - 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.org/ehd PUMP INSPECTION CHECK LIST Address:�,� Q �2 � LL Zr� e� Permit#: WHOM/ 99Z Inspection Date: � 2 Q Para meterlStandard Meets SJC Standards? ts/ Com ments/MeasuremenRecommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes, No ❑ NA ❑ Casing extends at least 12" above grade Yes No ❑ NA ❑ Casing extends at least 1" above pedestal Yes`R No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes. No ❑ NA ❑ Graded to allow drainage away from casing YesM No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes No ❑ NA ❑ Seal between all pipe columns and casing Yes ❑ No ❑ NA ❑ Sounding tube/air vents sealed properly Yes`S 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.K 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 N, No ❑ NA ❑ Air gap of at least 6" (same as pipe diameter) Yes N No ❑ NA ❑ MAINTENANCE: Well/Pump visible and protected from damage Yes" No ❑ NA ❑ Well/Pump free from excessive vegetation Yes No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes. 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 Ye- _ 1N o OTHER: Comments: % j2e o,.(j Inspected By: C Title: lr s Received By: Date: U EH -4200- 8/31/2015