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SAN 10AQUIN Environmental Health Department ,y -- C— LINTY ._.. stir -CMS Greorrit-s grow; here. Water Well Pump Inspection Check List Owner Name: DAVID & SHERRIE VAN VLIET TR Water Well Permit WP0043124 Date: May 02, 2022 Site Address: 17050 E LONE TREE RD Program: 4380 - PUMP PERMIT - NEW ESCALON, CA 95320 Service type: 051 - PUMP INSPECTION - NEW WELL Overall Comments: Inspection for new pump. No violations. Called owner before inspection. meceiveu uy: Inspector: Date: May 02, 2022 AARON GOODERHAM,REHS Printed Name and Title: Inspector Phone: No one onsite for inspection, (209) 616-3062 EHD Rev. 05/12/22 Page 1 of 1 Pump Inspection OIR 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd Parameter/Standard iMeets SJC 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 ❑ No ❑ N/A 3 Casing extends at least 1" above pedestal ■ Yes ❑ No ❑ N/A 4 Free of cracks/contiguous with annular seal ■ Yes ❑ No ❑ N/A 5 Graded to allow drainage away from casing ■ Yes ❑ No ❑ N/A SANITARY SEAL 6 Well is sealed between pump and casing ■ Yes ❑ No ❑ N/A 7 Seal between all pipe columns and casing ■ Yes ❑ No ❑ N/A 8 Sounding tube/air vents sealed properly ■ Yes ❑ No ❑ N/A 9 Chlorination port available and sealed properly F. 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 ❑ No ❑ NIA 12 No cross connections (chem feeders hooked to distrubution sys/ag flood irrigation from dom supply) ❑ Yes ■ No ❑ 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 ❑ No ❑ N/A 15 Well/pump free from excessive vegetation ■ Yes ❑ No ❑ NIA MISCELLANEOUS - If "no" is selected, attach an accurate map to permit 16 Permit drawing represents actual location of well . Yes ❑ No 17 Permit drawing sufficient to locate well in future ■ Yes ❑ No 18 Photograph taken and attached to record ■ Yes ❑ No Overall Comments: Inspection for new pump. No violations. Called owner before inspection. meceiveu uy: Inspector: Date: May 02, 2022 AARON GOODERHAM,REHS Printed Name and Title: Inspector Phone: No one onsite for inspection, (209) 616-3062 EHD Rev. 05/12/22 Page 1 of 1 Pump Inspection OIR 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd