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��� Environmental Health Department <br />SAN 10AQUIN <br />IU:i f`#Z. s --COU N T Y <br />r Grearn-,ss giov,-t hprp <br />Water Well Pump Inspection Check List <br />Owner Name: GUY TALLEY Water Well Permit WP0041719 Date: Sep 08, 2022 <br />Site Address: 16133 N MOORE RD Program: 4380 - PUMP PERMIT- NEW <br />LODI, CA 95242 Service type: 051 - PUMP INSPECTION - NEW WELL <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 />Parameter/Standard <br />Meets SJC Standards? Comments/Measurements/Recommendations <br />CEMENT PEDESTAL <br />1 <br />Dimensions of surface seal (2'x2'x4" minimum) <br />■ Yes <br />o No <br />❑ N/A <br />2 <br />Casing extends at least 12" above grade <br />■ Yes <br />o No <br />o N/A <br />3 <br />Casing extends at least 1" above pedestal <br />■ Yes <br />o No <br />o N/A <br />4 <br />Free of cracks/contiguous with annular seal <br />■ Yes <br />o No <br />o N/A <br />5 <br />Graded to allow drainage away from casing <br />■ Yes <br />❑ No <br />o N/A <br />SANITARY SEAL <br />6 <br />Well is sealed between pump and casing <br />■ Yes <br />o No <br />o N/A <br />7 <br />Seal between all pipe columns and casing <br />■ Yes <br />o No <br />o N/A <br />8 <br />Sounding tube/air vents sealed properly <br />■ Yes <br />o No <br />o N/A <br />9 <br />Chlorination port available and sealed properly <br />■ Yes o No o N/A <br />SAMPLE TAP AND BACKFLOW PREVENTION <br />10 <br />Non -threaded sample tap betwen well head and check valve or <br />within 3' of well head <br />■ Yes <br />o No <br />o N/A <br />11 <br />Adequately installed check valve or BFP device <br />■ Yes <br />o No <br />o N/A <br />12 <br />No cross connections (chem feeders hooked to distrubution <br />sys/ag flood irrigation from dom supply) <br />o Yes <br />■ No <br />o N/A <br />13 <br />Air gap of at least 6" (same as pipe diameter) <br />o Yes <br />o No <br />■ N/A <br />MAINTENANCE <br />14 <br />Well/pump visible and protected from damage <br />■ Yes <br />o No <br />o N/A <br />15 <br />Well/pump free from excessive vegetation <br />■ Yes <br />o No <br />o N/A <br />MISCELLANEOUS - If "no" is selected, attach an accurate map to permit <br />16 <br />17 <br />Permit drawing represents actual location of well■ <br />Permit drawing sufficient to locate well in future <br />Yes <br />■ Yes <br />c No <br />o No <br />18 <br />Photograph taken and attached to record <br />■ Yes <br />o 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 />