Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br /> Tefeplrone:(209)468-3420 Fax. (209)468-3433 Web:www.slgov.org/ehd <br /> PIMP INSPECTION CHECK LIST <br /> Address: Permit#: Inspection Date: <br /> N. 1J C 5 0 1s��� o U 22 'l <br /> aRu <br /> Parameter/Standard Meets SJC Standards? Cot�mcommentsIll ndati meths/ <br /> Recommendations <br /> CEMENT PEDESTAL: <br /> Dimensions of surface seal 2'x2'x4" minimum) Yes No ❑ NA❑ <br /> Casing extends at least 12" above grade Yes Q INo ❑ NA❑ <br /> Casing extends at least 1" above pedestal Yes No ❑ NA❑ <br /> Free of cracks/contiguous with annular seal Yes [0 No ❑ NA❑ <br /> Graded to allow drainage away from casing Yes [� No ❑ NA ❑ <br /> SANITARIA SEAL: <br /> Well is sealed between pump and casing jYesEj No ❑ NA❑ <br /> Seal between all pipe columns and casing Yes [ No ❑ NA❑ <br /> Sounding tube/air vents sealed properly Yes No ❑ NA❑ <br /> Chlorination port available and sealed properly Yes No ❑ I 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 Yes r� koE:1 NA❑ <br /> Adequately installed check valve or BFP device Yes No ❑ NA❑ <br /> No cross connections (ex: chemical feeders <br /> hooked to distribution system/ag flood irrigation <br /> from domestic supply) Yes ❑ No [ NA ❑ <br /> Air gap of at least 6" (same as pipe diameter) Yes ❑ No ❑ NA <br /> 9 <br /> MAINTENANCE: <br /> Weil/Pump visible and protected from damage YesNo ❑ I NA ❑ <br /> Well/Pump free from excessive vegetation Yes No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Iyes No ❑ <br /> Permit drawing sufficient to locate well in future IYes No ❑ If'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record IYes No ❑ <br /> OTHER: <br /> Comments: <br /> Inspected By: Title: . <br /> Received By: Date: <br />