SR0076922 - 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 Wel: www.sjgov.orq/ehd TMP INSPECTION CHECK LIST Address:/ ( I I �,S (,.J � C LI � o m C T ffo k a P� , O -76 g a a insp � yn 4e: dui �� Parameter/Standard 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 [2 No ❑ NA ❑ Casing extends at least 1" above pedestal Yes [2 No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes Q No ❑ NA ❑ Graded to allow drainage away from casing Yes [Z No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes 9 No ❑ NA ❑ Seal between all pipe columns and casing Yes [,r No ❑ NA n Sounding tubelair vents sealed properly Yes ❑ No ❑ NA E�r Chlorination port available and sealed properly Yes m No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes U No ❑ NA ❑ Adequately installed check valve or BFP device Yes No ❑ NA ❑ No cross connections (ex: chemical feeders hooked to distribution systemlag flood irrigation from domestic supply) I Yes ❑ No ❑ NA F�f _ Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ INA [Z MAINTENANCE: Well/Pump visible and protected from damage YesZ 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 0 No ❑ Photograph taken and attached to record Yes [0 No ❑ OTHER: - - I Comments: U, -J J 41 Inspected By: %U. s Title: ( I"eceived By: Date: