WP0041965 - 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.sogov.org/ehd PUMP INSPECTION CHECK LIST Address: 2_241-2c) N 9 F -r . Permit#: Inspection Date: Parameter/Standar 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 Yes ❑ No ❑ NA Casing extends at least 1" 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 ❑ No ❑ NA Seal between all pipe columns and casing Yes ❑ No ❑ NA [rr]' Sounding tube/air vents sealed properly Yes ❑ No ❑ NA [r Chlorination port available and sealed properly Yes ❑ No ❑ NA IV 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 [� Any 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) Yes ❑ No ❑ NA [R' 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 No ❑ Photograph taken and attached to record Yes [g No ❑ OTHER: Comments: ;5 C' tri one Svv} N k c&cA unci 1 Surf acxL \eve.\ ch'.P8 Inspected By: Title: Received By: Date: EH -4200- 8/31/2015