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SANADAQUIN Environmental Health Department <br /> I_'1COUNTY <br /> s_ ce <br /> Water Well Pump Inspection Check List <br /> Owner Name: PATRICIA&JACK HAMM Water Well Permit WP0043479 Date: Oct 04, 2022 <br /> Site Address: 5281 W KINGDON RD Program: 4381 -PUMP PERMIT-REPLACEMENT <br /> LODI, CA 95242 Service type: 050-PUMP INSPECTION <br /> Parameter/Standard Meets SJC StandaMs7 Comments/MeasummenWRammmendaticns <br /> CEMENT PEDESTAL _ __ _ <br /> 1 Dimensions of surface"at(2'x Wminimum) ora• •^'^ awn No cement pedestal around well casing. <br /> 2 Casin extends at least 12"above rade ow. o No •WP <br /> 3 Casing extends et least t"above pedestal or.. aNe .wA <br /> 4 Free of crecWcontiguous with annular seal .r•• eNo .rvA <br /> 5 Graded to allow drainageawa from cesin orae No .WA <br /> SANITARY SEAL <br /> 6 Well is sealetl between pump and casing .wa n Ni, own <br /> 7 Seal between Mine columns and casing .w• No aINA <br /> 8 Sounding tube/air vents sealed properly .ws oxo oNIA <br /> 9 Chlor natlon port available and sealed properly .w. o N. o WA <br /> SAMPLE TAP AND BACKFLOW PREVENTION <br /> 10 Non-threaded sample tap betwen well head and check valve or •res 1 4 1eIA <br /> within 3of wall head <br /> 11 Adequately Installed check valve or BFP device •we oNo owA <br /> 12 No cross connections(chem feeders <br /> hooketl to distrubution •m .No own <br /> s sa flood irri anon from dom su i <br /> 13 Air gap of at least 6"(same as pipe diameter) are• ow .NIA <br /> MAINTENANCE <br /> 14 Well/pump visible and pralected from damage .res -Ne �wA <br /> 15 Well/pump free from excessive vegetation .res N. o. <br /> MISCELLANEOUS-If"no"Is selected,attach an accurate map to permit <br /> 16 Permit drawin represents acAual location of well I .res �No <br /> 17 Permit drawing sufficient to locale well in future .w• oao <br /> 18 Photograph taken and attached to receN I •wa o Na <br /> Overall Comments: <br /> Received <br /> Date: Inspector: <br /> NASEEM AHMED, Senior REHS <br /> Printed No"and Title: Inspector Phone: <br /> END Rev.0511=2 Page 1 of 1 Pump Irupeclbn OR <br /> 1868 E. Hazelton Avenue I Stockton,California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />