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WP0041725
EnvironmentalHealth
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24725
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4200/4300 - Liquid Waste/Water Well Permits
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WP0041725
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Entry Properties
Last modified
3/16/2022 11:00:06 AM
Creation date
3/16/2022 10:52:56 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4200/4300 - Liquid Waste/Water Well Permits
RECORD_ID
WP0041725
PE
4380
STREET_NUMBER
24725
Direction
S
STREET_NAME
CLOUGH
STREET_TYPE
RD
City
ESCALON
Zip
95320-
APN
24713021
ENTERED_DATE
2/22/2021 12:00:00 AM
SITE_LOCATION
24725 S CLOUGH RD
P_LOCATION
99
P_DISTRICT
004
QC Status
Approved
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SJGOV\tsok
Tags
EHD - Public
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SAN .JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />PUMP INSPECTION CHECK LIST <br />Address: <br />V\ i"�'\'< �_ �—_SL.P. ,-o---1 <br />Permit#: <br />I? S <br />Inspection Date: <br />\t 2Z <br />Parameter/Standard <br />Meets SJC Standards? <br />Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (extends 2' from <br />casing) <br />Yes (z <br />No ❑ <br />NA ❑ <br />Casing extends at least 12" above grade <br />Yes 1A <br />No ❑ <br />NA ❑ <br />Casing extends at least 1" above pedestal <br />YesE6 <br />No ❑ <br />NA ❑ <br />Free of cracks/contiguous with annular seal <br />Yes <br />No ❑ INA <br />❑ <br />Graded to allow drainage away from casing <br />Yes <br />No ❑ INA <br />❑ <br />SANITARY SEAL: <br />Well is sealed between pump and casing <br />Yes <br />No ❑ <br />NA ❑ <br />Seal between all pipe columns and casing <br />Yes <br />No ❑ <br />NA ❑ <br />Sounding tube/air vents sealed properly <br />Yes <br />No ❑ <br />NA ❑ <br />Chlorination port available and sealed properly <br />Yes <br />No ❑ <br />NA ❑ <br />SAMPLE TAP AND BACKFLOW PREVENTION: <br />Non -threaded sample tap between well head and <br />check valve or within 3' of well head <br />Yes�z <br />No ❑ <br />NA ❑ <br />Adequately installed check valve or BFP device <br />Yes U <br />No ❑ <br />NA ❑ <br />Cross connections (ex: chemical feeders hooked <br />to distribution system/ag flood irrigation from <br />domestic supply) <br />Yes ❑ <br />No [Z] <br />NA <br />Air gap of at least 6" same as pipe diameter <br />Yes ❑ <br />No ❑ <br />NA �] <br />MAINTENANCE: <br />Well/Pump visible and protected from damage <br />Yes <br />No ❑ <br />NA ❑ <br />Well/Pump free from excessive vegetation <br />Yes [� <br />No ❑ <br />NA ❑ <br />MISCELLANEOUS: i <br />Permit drawing represents actual location of well <br />Yesft <br />No ❑ <br />is selected, attach an accurate map to permit <br />Permit drawing sufficient to locate well in future <br />YesNo <br />[:]Una' <br />Photograph taken and attached to record <br />Yes <br />No ❑ <br />OTHER: <br />Comments: <br />Inspected By: Aaron Gooderham <br />Title: Registered Environmental Health Specialist <br />Received B <br />Date: <br />EH -4200- 8/31/2015 <br />
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