WP0041849 - 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 Web: www.sigov.org/ehd PUMP INSPECTION CHECK LIST Address: - � 2 L � w�.�t �" Permit#:Inspe w 00 qI$� tion Date: Parameter/Stand rd Meets SJC Standards? Comments/Me surement / Recommendations CEMENT PEDESTAL: Dimensions of surface seal (2'x2'x4" minimum) Yeses No ❑ NA ❑ Casing extends at least 12" above grade Yes No ❑ NA ❑ Casing extends at least 1" above pedestal Yeses No ❑ NA ❑ Free of cracks/contiguous with annular seal Ye No ❑ NA ❑ Graded to allow drainage away from casing Ye No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yeslo No ❑ NA ❑ Seal between all pipe columns and casing Ye No ❑ NA ❑ Sounding tube/air vents sealed properly Yes o ❑ NA ❑ Chlorination port available and sealed properly Yelrl No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes ❑ No ❑ NA Adequately installed check valve or BFP device Yes ❑ No ❑ NA No cross connections (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Ye No ❑ NA ❑ Air gap of at least 6" (same as pipe diameter) YesO No ❑ NA ❑ MAINTENANCE: Well/Pump visible and protected from damage Yese No ❑ NA ❑ Well/Pump free from excessive vegetation Yes No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Ye 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 01 Yes No ❑ OTHER: Comments: Inspected By: - C>L Title: IZ tk S Received By: Date: CZ -1 — 21, -- _ 0 f ��EH-4200- 8/31/2015