WP0042474 - Laserfiche WebLink

Home Browse Search

4 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sogov.org/ehd PUMP INSPECTION CHECK LIST Address:G/� 4 /'/ /V °r'71 Permit#: P %�/-/j �V l ZY�I In /p to Date: Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yes rR No ❑ NA ❑ Casing extends at least 12" above grade Yes No ❑ NA ❑ Casing extends at least 1" above pedestal Yes No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes N. No ❑ NA ❑ Graded to allow drainage away from casing Yes C3 No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes 5j No ❑ NA ❑ Seal between all pipe columns and casing Yesj No ❑ NA ❑ Sounding tube/air vents sealed properly Yes 'R 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 N No ❑ NA ❑ Adequately installed check valve or BFP device Yes a No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes No ❑ NA ❑ Air gap of at least 6" (same as pipe diameter) IYes a No ❑ INA ❑ MAINTENANCE: Well/Pump visible and protected from damage Yes P4 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." No ❑ Photograph taken and attached to record Yes ❑ No OTHER: Comments: I)Ve- c -G, sJ-(- Inspected By: LA,(� Title: ice. jT Received By: I Date: EH -4200- 8/31/2015