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.sjgov.org/ehd <br />PUMP INSPECTION CHECK LIST <br />Address: 9 6c,..3 ru.:_r-r , 4 ,,,, cibc../4) <br />vt -1 •-i Permit#: <br />1A412 0 -3 9 fer 7 <br />Ins_pection JDatg: <br />5/a1-//z-1 <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal (2'x2'x4" minimum) Yes 9:1 No LI NA El <br />Casing extends at least 12" above grade Yes gr No El NA El <br />Casing extends at least 1" above pedestal Yes174' No LI NA LII <br />Free of cracks/contiguous with annular seal Yes LI No NA NA Cre—c-k-S sm e-ezle—,Sle-1 <br />Graded to allow drainage away from casing Yes g No LII NA LII <br />SANITARY SEAL: <br />Well is sealed between pump and casing Yes A No El NA El <br />Seal between all pipe columns and casing Yeslti No LII NA LII <br />Sounding tube/air vents sealed properly Yes V No NA El <br />Chlorination port available and sealed properly Yes lg No El NA LII <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 tz No El NA El <br />Adequately installed check valve or BFP device Yes 5[ No LI NA <br />No cross connections (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) Yes El No I I NAK <br />Air gap of at least 6" (same as pipe diameter) Yes Lii No NA 1% <br />MAINTENANCE: <br />Well/Pump visible and protected from damage Yes lgj No NA El <br />Well/Pump free from excessive vegetation Yes 1711' No NA El <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well Yes No LI <br />If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes 71- No <br />Photograph taken and attached to record Yes r?9-- No El <br />OTHER: <br />Comments: <br />6/2 6 I <br />(40-(ACP <br />( ()in <br />-0,4‘ <br />r <br />F-- <br />- <br />.20 <br />(.4,--e_ <br />l cit,t,e, -ko c <br />z__1 - 0 wiip,r <br />, rt pe-eW-60-1 <br />4--.0 ce-z-c*- <br />rixtk5 iii <br />soek+ <br />(4t&ve___ <br />ceod, <br />Pe-cle-S --&---1 <br />c ic 1-1,te-c <br />5e-e,--6-4 <br />a. y-D ,,,,,,ei irve,-11 <br />hot/t 149 <br />lim'-[/,7 c2G4iK4--e,-6, <br />(/ce-i. ; yiq , <br />-111°(-- <br />Inspected By: (I's- A-C)=.0-.514-; Title: 12-e74S <br />Received By: Date: ,,2_ea_I <br />EH-4200- 8/31/2015