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S A N J 0 A Q U I N Environmental Health Department <br /> Water Well Pump Inspection Check List <br /> Owner Name: JAVIER ACEVES Water Well Permit WP0043391 Date: Aug 04, 2022 <br /> Site Address: 19176 S SANTA FE RD Program: 4381 - PUMP PERMIT- REPLACEMENT <br /> ESCALON, CA 95320 Service type: 050 - PUMP INSPECTION <br /> Parameter/Standard Meets SJC Standards? Comments/Measurements/Recommendations <br /> CEMENT PEDESTAL <br /> 1 1 Dimensions of surface seal(2'x2'x4"minimum) .Yes No N/A <br /> 2 Casing extends at least 12"above grade ■Yes u No ❑N/A <br /> 3 Casing extends at least 1"above pedestal .Yes o No u N/A <br /> 4 Free of cracks/contiguous with annular seal .Yes o No o N/A <br /> 5 Graded to allow drainage away from casing .Yes o No o N/A <br /> SANITARY SEAL <br /> 6 Well is sealed between pump and casing .Yes u No o N/A <br /> 7 Seal between all pipe columns and casing .Yes u No u N/A <br /> 8 Sounding tube/air vents sealed properly .Yes c No u N/A <br /> 9 Chlorination port available and sealed properly .Yes a No u N/A <br /> SAMPLE TAP AND BACKFLOW PREVENTION <br /> 10 Non-threaded sample tap betwen well head and check valve or u Yes .No u N/A <br /> within 3'of well head <br /> 11 Adequately installed check valve or BFP device .Yes o No u N/A <br /> 12 No cross connections(chem feeders hooked to distrubution u Yes .No o N/A <br /> sys/ag flood irrigation from dom supply) <br /> 13 Air gap of at least 6"(same as pipe diameter) ❑Yes u No ■N/A <br /> MAINTENANCE <br /> 14 Well/pump visible and protected from damage .Yes u No u N/A <br /> 15 Well/pump free from excessive vegetation .Yes No - NA <br /> MISCELLANEOUS - If"no" is selected, attach an accurate map to permit <br /> 16 Permit drawing represents actual location of well .ye, No <br /> 17 Permit drawing sufficient to locate well in future .Yes o No <br /> 18 Photograph taken and attached to record .Yes o No <br /> Overall Comments: <br /> Inspection for a pump for a new well. No sample tap so I was unable to take samples. <br /> Received by: Date: Inspector: <br /> AARON GOODERHAM, REHS <br /> Printed Name and Title: Inspector Phone: <br /> (209) 616-3062 <br /> l Rev.05/12/22 Page 1 of 1 Pump Inspection OIR <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjgov.org/ehd <br />