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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.smgov.org/ehd <br />PUMP INSPECTION CHECK LIST <br />Address: Permit#: Inspection Date: <br />8000 E Kettleman Ln., Lodi WP0041606 11/10/21 <br />Parameter/Standard Meets SJC Standards? Comments/Measurements/ <br />Recommendations <br />CEMENT PEDESTAL: <br />Dimensions of surface seal 2'x2'x4" minimum <br />Yes <br />Casing extends at least 12" above grade <br />Yes <br />Casing extends at least 1" above pedestal <br />Yes <br />Free of cracks/contiguous with annular seal <br />Yes <br />Graded to allow drainage away from casing <br />Yes <br />SANITARY SEAL: <br />Well is sealed between pump and casing <br />Yes <br />Seal between all pipe columns and casing <br />Yes <br />Sounding tube/air vents sealed properly <br />Yes <br />Chlorination port available and sealed properly <br />Yes <br />SAMPLE TAP AND BACKFLOW PREVENTION: <br />Non -threaded sample tap between well head and <br />check valve or within 3' of well head <br />Yes <br />Adequately installed check valve or BFP device <br />Yes <br />Any cross connections? (ex: chemical feeders <br />hooked to distribution system/ag flood irrigation <br />from domestic supply) <br />Yes <br />Air gap of at least 6" (same as pipe diameter) <br />Yes <br />MAINTENANCE: <br />Well/Pump visible and protected from damage <br />Yes <br />Well/Pump free from excessive vegetation <br />Yes <br />MISCELLANEOUS: <br />Permit drawing represents actual location of well <br />Permit drawing sufficient to locate well in future <br />Photograph taken and attached to record <br />OTHER: <br />Comments: <br />No ❑ NA ❑ <br />No El NA EI <br />No NA❑ <br />No ❑ NA ❑ <br />No ❑ NA ❑ <br />No ❑ NA <br />No ❑ NA <br />No ❑ NA <br />No I—I NA <br />in—Elm <br />►��� <br />No ❑ INA <br />No I-1 NA <br />No L] INA❑ <br />No [:1 INA❑ <br />Yes No ❑ <br />Yes ® No ❑ if 'no' is selected, attach an accurate map to permit <br />Yes IN No 1-1 <br />Ilnsoected Bv: ! 1 / , .l(Title: �7 1:� L' L 1—= <br />l Received <br />EH -4200- <br />Date: <br />8/31/2015 <br />