Laserfiche WebLink
SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East HazeIton Avenue. Stockton. CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.orq/ehd <br />PUMP INSPECTION CHECK LIST <br />Address: --n 1 2- (-IL 4-ble Pei (4i-vjen (A tc--)t, <br />Permit: <br />c„2.,0-,-.1-(D .71 11 <br />Inspection Date: <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes Ri No Li NA Li <br />Casing extends at least 12" above grade Yes g No Li NA Li <br />Casing extends at least 1" above pedestal Yes a. No Li NA LI <br />Free of cracks/contiguous with annular seal Yes R2/ No Li NA Li <br />Graded to allow drainage away from casing Yes Er No LI NA LI <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes Er No Li NA LI <br />Seal between all pipe columns and casing Yes 12 No Li NA Li <br />Sounding tube/air vents sealed properly Yes El' No LI NA Li <br />Chlorination port available and sealed properly Yes gr No Li NA Li <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 2/ No Li NA LI <br />Adequately installed check valve or BFP device Yes Er No Li NA Li <br />Any cross connections? (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes Li No Li NA Er - <br />Air gap of at least 6" (same as pipe diameter) Yes Li No Li - NA M- <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes e No Li NA Li <br />Well/Pump free from excessive vegetation Yes El/ No Li NA Li <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes Er;No <br />Yes i, LE' <br />Yes <br />Li <br />No Li <br />No Li <br />If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future <br />ePhotograph taken and attached to record <br />OTHER: <br />Comments: <br />Inspected By: rc„.it;-) (4,- cairn: wi 0 2_ Title: 0/ itS. ra ts '-"L <br />Received By: Date: s-T /(c /2,./ -,--) <br />EH-4200- 8/31/2015