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�s`"CL <br /> SAN J OAQU I N <br /> Environmental Health Department <br /> W � 'd� ` --- (:)u N r Y-- <br /> Fsz '' Greor,7ess grows here. <br /> Water Well Pump Inspection Check List <br /> Owner Name: MARY WOLF Water Well Permit: WP0040989 Date: Sep 14, 2022 <br /> Site Address: 1422 MEADOWAVE Program: 4381 - PUMP PERMIT- REPLACEMENT <br /> STOCKTON, CA 95207 Service type: 003 - INSPECTION/ REINSPECTION(No Charge) <br /> Parameter/Standard Meets SJC Standards? Comments/Measureme nts/Recommendations <br /> CEMENT PEDESTAL <br /> 1 Dimensions of surface seal(2'x2'x4"minimum) ■Yes o No D N/A <br /> 2 Casing extends at least 12"above grade ■Yes o No o N/A <br /> 3 Casing extends at least 1"above pedestal ■Yes a No o N/A <br /> 4 Free of cracks/contiguous with annular seal ■Yes a No o N/A <br /> 5 Graded to allow drainage away from casing ■Yes 7 No o N/A <br /> SANITARY SEAL <br /> 6 Well is sealed between pump and casing ■Yes o No o N/A <br /> 7 Seal between all pipe columns and casing ■Yes o No a N/A <br /> 8 Sounding tube/air vents sealed properly ■Yes o No c N/A <br /> 9 Chlorination port available and sealed properly ■Yes o No o N/A <br /> SAMPLE TAP AND BACKFLOW PREVENTION <br /> 10 Non-threaded sample tap betwen well head and check valve or ■Yes o No o N/A <br /> within 3'of well head <br /> 11 Adequately installed check valve or BFP device ■Yes o No a N/A <br /> 12 No cross connections(chem feeders hooked to distrubution o Yes ■No N/A <br /> sys/ag flood irrigation from dom supply) <br /> 13 Air gap of at least 6"(same as pipe diameter) r Yes o No ■N/A <br /> MAINTENANCE <br /> 14 Well/pump visible and protected from damage ■Yes o No o N/A <br /> 15 Well/pump free from excessive vegetation ■Yes ❑No o N/A <br /> MISCELLANEOUS - If"no" is selected, attach an accurate map to permit <br /> 16 Permit drawing represents actual location of well .Yes No <br /> 17 Permit drawing sufficient to locate well in future ■Yes o No <br /> 18 Photograph taken and attached to record ■Yes c No <br /> Overall Comments: <br /> Received by: Date: Inspector: <br /> NASEEM AHMED, Senior REHS <br /> Printed Name and Title: Inspector Phone: <br /> EHD Rev.05/12/22 Page 1 of 1 Pump Inspection OIR <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />