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oPq�f" SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E Weber Avenue 3rd Floor Stockton • CA 95202-2708 (209)468-3420 • Fax:(209)464-0138 • Web:www.co.san-joaquin.ca.us/ehd cq Cti`oai+� SOIL SUITABILITY STUDY REQUIREMENTS CHECKLIST A4 32�' PA#: O�— 7d SITE LOCATION: d/ �� 4. �SCQOY�- REPORT DATE: y /3 /�Cjja6 S = Sufficient San Joaquin County Development Title Chapter 9-1105,Section 9-1105.2 I = Insufficient S I 1.0 INTRODUCTION & PROPOSED DEVELOPMENT SECTION Eg/ ❑ 1.1 Description of site, including zoning information{- [� ❑ 1.2 Description of proposed development. T I61C 1 f E�lz ❑ 1.3 Parcel vicinity location map.: L^J./ ❑ 1.4 Site map showing location of all items on parcels (i.e., structures, drives,wells, septic systems, large trees, pastures, pools, natural drainage courses, ponds,waterways, etc.) 2.0 PRESENT AND PAST USES OF THE SITE SECTION [� ❑ 2.1 Discussion of past and present uses at the site to assess potential problems. 3.0 EXISTING AND PROPOSED SEPTIC TANK USAGE SECTION [�/ ❑ 3.1 Description of exiting on-site septic tank usage(system types, age, functioning/repair rates). > Q ❑ 3.2 Site septic permit history (number/types/dates of permits, age of system, permit numbers,copies in report)(,j� " [� ❑ 3.3 Discussion of on-site septic tank repair history. , 17 3 [� ❑ 3.4 Description of existing septic tank usage in the general area(system types, ages, functioning/repair rates, / proximity to parcel). �uJ ❑ 3.5 General area septic permit(s history(number/types/dates of permits, age of system, permit numbers, copies in report). � 3 E3// ❑ 3.6 Discussion of general area septic tank repair history. \L �-�( y [3 ❑ 3.7 Description of proposed or expected maximum(including second unit dwellings) septic ttlnk usage on site. 4.0 GROUNDWATER INFORMATION SECTION [� ❑ 4.1 Description of the depth and gradient of groundwater in the general area. [� ❑ 4.2 Description/discussion of any existing and/or potential groundwater contamination issues in the general location of the site. E9/ F-14.3 Description of location address/APN), type and construction of well and location (well head/kitchen tap)where water sample(s)were obtained u C� [[� ❑ 4.4 Description of constituents bein tested for in the water sample. ) �/ 1 u � ❑ 4.5 Description of how sample was obtained, handled, stored, and transpo ed to the lat6a 6/ ❑ 4.6 Complete Chain of Custody document, including printed and signed name of third party sampler, condition of sample and date and time the sample was submitted to the lab. For Laboratory samplers, complete laboratory report to include the above noted information. 5.0 SOIL PROFILE INFORMATION SECTION ❑ 5.1 Site map showing the location,with dimensions, of the soil profile pit on the parcel. (f 71su- ❑ 5.2 Description of soil profile pit including depth and dimensions. ❑ 5.3 Description of soil lithology as noted from test pit by appropriate professional u ing industry standard protocol. ❑ 5.4 Discussion of soil lithology as related to future onsite septic uses. EHD 26-02-003 Pagel of3 `_ Soil Suitability Checklist