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SAN JOAQUIN Environmental Health Department <br /> 1,jr.! -ry <br /> Water Well Pump Inspection Check List <br /> Owner Name: FERRERO FAMILY FARMS LTD Water Well Permit: WP0042705 Date: Aug 18, 2022 <br /> Site Address: 21433 N DEVRIES RD Program: 4381 - PUMP PERMIT- REPLACEMENT <br /> LODI, CA 95242 Service type: 003 - INSPECTION/ REINSPECTION(No Charge) <br /> Parameter/Standard iMeets SJC Standards? Comments/Measurements/Recommendations <br /> CEMENT PEDESTAL <br /> 1 Dimensions of surface seal(2'x2'x4"minimum) .Yes o No o N/A <br /> 2 Casing extends at least 12"above grade o Yes ■No u N/A Existing well. <br /> 3 Casing extends at least 1"above pedestal ■Yes o No o N/A <br /> 4 Free of cracks/contiguous with annular seal ■Yes a No a N/A <br /> 5 Graded to allow drainage away from casing ■Yes o No o N/A <br /> SANITARY SEAL <br /> 6 Well is sealed between pump and casing ■Yes a No a N/A <br /> 7 Seal between all pipe columns and casing ■Yes o No o N/A <br /> 8 Sounding tube/air vents sealed properly ■Yes o No o 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 a No a 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 o N/A <br /> sys/ag flood irrigation from dom supply) <br /> 13 Air gap of at least 6"(same as pipe diameter) o Yes a 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 o 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 No <br /> 18 Photograph taken and attached to record .Yes No <br /> Overall Comments: <br /> Received by: <br /> 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 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />