Laserfiche WebLink
SAN JOAQUIN <br />Environmental Health Department <br />Water Well Pump Inspection Check List <br />Owner Name: DI LEO, GAYLE TR ETAL Water Well Permit: WP0043562 Date: Aug 17, 2022 <br />Site Address: 5841 E HWY 26 Program: 4380 - PUMP PERMIT - NEW <br />STOCKTON, CA 95215 Service type: 051 - PUMP INSPECTION - NEW WELL <br />Overall Comments: <br />Wellhead is sealed and meets SJC pump permitting requirements. <br />Received by: Date: Inspector: <br />FRANK GIRARDI, Senior REHS <br />Printed Name and Title: Inspector Phone: <br />(209) 616-3044 <br />EHD Rev. 05/12/22 Page 1 of 1 Pump Inspection OIR <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />Parameter/Standard <br />Meets SJC Standards? Comments/Measurements/Recommendations <br />CEMENT PEDESTAL <br />1 <br />Dimensions of surface seal (2'x2'x4" minimum) <br />■ Yes ❑ No ❑ N/A <br />2 <br />Casing extends at least 12" above grade <br />■ Yes ❑ No ❑ N/A <br />3 <br />Casing extends at least V above pedestal <br />■ Yes ❑ No ❑ N/A <br />4 <br />Free of cracks/contiguous with annular seal <br />■ Yes ❑ No o N/A <br />5 <br />Graded to allow drainage away from casing <br />■ Yes ❑ No ❑ N/A <br />SANITARY SEAL <br />6 <br />Well is sealed between pump and casing <br />. Yes ;No N/A <br />7 <br />Seal between all pipe columns and casing <br />■ Yes ❑ No ❑ N/A <br />8 <br />Sounding tube/air vents sealed properly <br />■ Yes o No ❑ N/A <br />9 <br />Chlorination port available and sealed properly <br />■ Yes ❑ No ❑ N/A <br />SAMPLE TAP AND BACKFLOW PREVENTION <br />10 <br />Non -threaded sample tap betwen well head and check valve or <br />within 3' of well head <br />❑ Yes ❑ No ■ N/A <br />11 <br />Adequately installed check valve or BFP device <br />■ Yes n No n N/A <br />12 <br />No cross connections (chem feeders hooked to distrubution <br />sys/ag flood irrigation from dom supply) <br />■ Yes o No ❑ N/A <br />13 <br />Air gap of at least 6" (same as pipe diameter) <br />❑ Yes ❑ No ■ N/A <br />MAINTENANCE <br />14 <br />Well/pump visible and protected from damage <br />■ Yes ❑ No ❑ N/A <br />15 <br />Well/pump free from excessive vegetation <br />■ Yes - No - N/A <br />MISCELLANEOUS - If "no" is selected, attach an accurate map to permit <br />16 <br />Permit drawing represents actual location of well <br />• Yes No <br />17 <br />18 <br />Permit drawing sufficient to locate well in future <br />Photograph taken and attached to record <br />■ Yes ❑ No <br />n Yes ■ No <br />Overall Comments: <br />Wellhead is sealed and meets SJC pump permitting requirements. <br />Received by: Date: Inspector: <br />FRANK GIRARDI, Senior REHS <br />Printed Name and Title: Inspector Phone: <br />(209) 616-3044 <br />EHD Rev. 05/12/22 Page 1 of 1 Pump Inspection OIR <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />