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SANJOAQUIN C "7)1,_; lv,1 T Y Environmental Health Department Water Well Pump Inspection Check List Owner Name: BROVELLI, CATHERINE A TR Water Well Permit: WP0043512 Date: Aug 29, 2022 Site Address: 5522 N HARRISON ST Program: 4381 -PUMP PERMIT -REPLACEMENT LINDEN, CA 95236 Service type: 050 - PUMP INSPECTION Overall Comments: Wellhead is sealed and meets SJC pump permitting requirements Received by: Date: Inspector: FRANK GIRARDI, Senior REHS Printed Name and Title: Inspector Phone: (209) 616-3044 EHD Rev. 05/12/22 Page 1 of 1 Pump Inspection OR 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd Parameter/Standard MeetSJC Standards? Comments/Measurements/Recommendations CEMENT PEDESTAL 1 Dimensions of surface seal (2'x2'x4" minimum) . Yes ❑ No ❑ N/A 2 Casing extends at least 12" above grade ■ Yes o No o N/A 3 Casing extends at least 1" above pedestal ■ Yes ❑ No ❑ N/A 4 Free of cracks/contiguous with annular seal ■ Yes o No o N/A 5 Graded to allow drainage away from casing ■ Yes o No o N/A SANITARY SEAL 6 Well is sealed between pump and casing . Yes ❑ No ❑ N/A 7 8 Seal between all pipe columns and casing Sounding tube/air vents sealed properly ■ Yes ❑ No o N/A ■ Yes ❑ No ❑ N/A 9 Chlorination port available and sealed properly ■ Yes o No ❑ N/A SAMPLE TAP AND BACKFLOW PREVENTION 10 Non -threaded sample tap betwen well head and check valve or within 3' of well head ■ Yes ❑ No ❑ N/A 11 Adequately installed check valve or BFP device . Yes o No o N/A 12 No cross connections (chem feeders hooked to distrubution sys/ag flood irrigation from dom supply) ■ Yes o No o N/A 13 Air gap of at least 6" (same as pipe diameter) ❑ Yes ❑ No ■ N/A MAINTENANCE 14 Well/pump visible and protected from damage ■ Yes o No o N/A 15 Well/pump free from excessive vegetation . Yes No N/A MISCELLANEOUS - If "no" is selected, attach an accurate map to permit 16 Permit drawing represents actual location of well . ves - o 17 Permit drawing sufficient to locate well in future ■ Yes o No 18 Photograph taken and attached to record ❑ Yes ■ No Overall Comments: Wellhead is sealed and meets SJC pump permitting requirements Received by: Date: Inspector: FRANK GIRARDI, Senior REHS Printed Name and Title: Inspector Phone: (209) 616-3044 EHD Rev. 05/12/22 Page 1 of 1 Pump Inspection OR 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd