Laserfiche WebLink
S ' <br /> 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: Permit#• Inspe tion ate: <br /> o a Lr�� WPUV3� 1of v ,) /g <br /> Parameter/Standard = Meets SJC Standards? Comments/Measurements/ <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 V' No ❑ NA ❑ <br /> Casing extends at least 1" above pedestal Yes ✓❑ No ❑ NA ❑ <br /> Free of cracks/contiguous with annular seal Yes ❑ No ;' NA ❑ s L r;` (,.Um,en+ <br /> Graded to allow drainage away from casing Yes ❑ No ❑ NA ❑ <br /> SANITARY SEAL: <br /> Well is sealed between pump and casing Yes J�j No ❑ NA❑ <br /> Seal between all pipe columns and casing Yes 0 No ❑ NA ❑ <br /> Sounding tube/air vents sealed properly Yes ❑ No ❑ NA❑ <br /> Chlorination port available and sealed properly lYes © No ❑ 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 ® No ❑ NA ❑ <br /> Adequately installed check valve or BFP device Yes W] 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 /> MAINTENANCE: <br /> Well/Pump visible and protected from damage Yes ® No ❑ NA ❑ <br /> Well/Pump free from excessive vegetation Yes ® No ❑ NA❑ <br /> MISCELLANEOUS: <br /> Permit drawing represents actual location of well Yes ® No ❑ <br /> Permit drawing sufficient to locate well in future Yes 9 No ❑ If'no'is selected,attach an accurate map to permit <br /> Photograph taken and attached to record Yes k] No ❑ <br /> OTHER: <br /> Comments: I 4 J <br /> Cr0" <br /> j V Title: pf,, <br /> Inspected By: L�,c.� � <br /> Received By: Date: <br /> EH-4200- 8131/2015 <br />