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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd PUMP INSPECTION CHECK LIST Address: 16430 N Locust Tree Rd., Lodi Permit#: WP0042451 Inspection Date: 2/28/22 Parameter/Standard Meets SJC Standards? Comments/Measurements/ Rccomllicndatlons CEMENT PEDESTAL: Dimensions of surface seal 2'x2'x4" minimum Yes ® No ❑ NA ❑ Casing extends at least 12" above grade Yes ® No ❑ NA ❑ Casing extends at least 1" above pedestal Yes ® No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes ® No ❑ NA ❑ Graded to allow drainage away from casing Yes ® No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes ® No ❑ NA ❑ Seal between all pipe columns and casing . Yes ® No ❑ NA ❑ Sounding tube/air vents sealed properly Yes ® No ❑ NA ❑ Chlorination port available and sealed properly Yes ❑ No ® NA ❑ Chlorination plug missing from wellhead., SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes ❑ No ® NA ❑ Provide a non -treaded sample tap on wellhead side of checkvalve. Adequately installed check valve or BFP device Yes ® No ❑ NA ❑ Any cross connections? (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes ❑ No ❑ NA Air gap of at least 6" (same as pipe diameter), Yes ❑ No ❑ NA MAINTENANCE: Well/Pump visible and protected from damage Yes ® No ❑ NA ❑ Well/Pump free from excessive ve etation Yes ® No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes ® No ❑ If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes ® No ❑ Photograph taken and attached to record Yes ® No ❑ OTHER: Abandoned well: Yes ❑ NO ® Obtain permits to destroy the well. Comments: The pump inspection conducted this date revealed the following: 1) No sample tap is provided on the wellhead side of the checkvalve. Provide. 2) The Chlorination port at the well head is missing which is creating an open hole into the well. Provide a chlorination port to properly seal and eliminate wellhead openings. 3) The well is not connected to the distribution system and not in use at this time. If the well is not in use for one (1) year, it will be considered an "Abandoned Well" in which it will be required to obtain proper permits to destroy the well. (C Health & Safety Code, Section 115700(a)(b)(d); CA Health & Safety Code, Section 115710; SJC Ord. Code, Title 9, Section 9-1115.5 — Wel Regulations, SJC Water Well Standards, Section 6.1.). Obtain proper permits to destroy the well. Inspected By: Frank Girardi Title: Senior REHS Received By: Mailed to: STOLTMAN, JAMES P & TRACY L; 2657 DOUGLAS FIR DR., LODI., CA 95242. Date: EH -4200- 8/31/2015