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¢au1 SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />id 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />.•.... Wap Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sjgov.org/ehd <br />SOIL SUITABILITY STUDY REQUIREMENTS CHECKLIST <br />- <br />SITE LOCATION: "[ L WlJ`-(_oki -._— PA #: �f <br />REPORT DATE_ I if �� L <br />S = Sufficient <br />1 = Insufficient <br />San Joaquin County Development Title Chapter 9-1105, Section 9-1105.2 <br />S <br />1 <br />7.0 <br />INTRODUCTION & PROPOSED DEVELOPMENT SECTION <br />3.2 <br />❑ <br />1.1 <br />Description of site, including zoning information. <br />Zr <br />❑ <br />1.2 <br />Description of proposed development. <br />Z' <br />❑ <br />1.3 <br />Parcel vicinity location map. <br />Description of location (address/APN), type and construction of well and location (well head/kitchen tap) where <br />❑ <br />1-4 <br />Site map showing location of all items on parcels (i.e., structures, drives, wells, septic systems, large trees, <br />3.5 <br />General area septic permit history (numberltypes/dates of permits, age of system, permit numbers, copies in <br />❑ <br />pastures, pools, natural drainage courses, ponds, waterways, etc.) <br />2.0 PRESENT AND PAST USES OF THE SITE SECTION <br />❑ 2.1 Discussion of past and present uses at the site to assess potential problems. <br />3.0 EXISTING AND PROPOSED SEPTIC TANK USAGE SECTION <br />Er <br />❑ <br />3.1 <br />Description of exiting on-site septic tank usage (system types, age, functioning/repair rates). <br />❑ <br />❑ <br />3.2 <br />Site septic permit history (number/types/dates of permits, age of system, permit numbers, copies in report). <br />Z❑ <br />4.2 <br />3.3 <br />Discussion of on-site septic tank repair history. <br />.� <br />❑ <br />3.4 <br />Description of existing septic tank usage in the general area (system types, ages, functioning/repair rates, <br />❑ <br />4.3 <br />Description of location (address/APN), type and construction of well and location (well head/kitchen tap) where <br />proximity to parcel) - <br />0 <br />❑ <br />3.5 <br />General area septic permit history (numberltypes/dates of permits, age of system, permit numbers, copies in <br />❑ <br />4.4 <br />Description of constituents being tested for in the water sample - <br />report). <br />❑ 3.6 Discussion of general area septic tank repair history. <br />.E3'- ❑ 3.7 Description of proposed or expected maximum (including second unit dwellings) septic tank usage on site <br />4,0 GROUNDWATER INFORMATION SECTION <br />,� <br />❑ <br />4.1 <br />Description of the depth and gradient of groundwater in the general area. <br />❑ <br />4.2 <br />Description/discussion of any existing and/or potential groundwater contamination issues in the general location <br />of the site. <br />❑ <br />4.3 <br />Description of location (address/APN), type and construction of well and location (well head/kitchen tap) where <br />water sample(s) were obtained. <br />❑ <br />4.4 <br />Description of constituents being tested for in the water sample - <br />,0' <br />F] <br />4.5 <br />Description of how sample was obtained, handled, stored, and transported to the lab. <br />[.]� <br />❑ <br />4.6 <br />Complete Chain of Custody document, including printed and signed name of third party sampler, condition of <br />sample and date and time the sample was submitted to the lab. For Laboratory samplers, complete laboratory <br />report to include the above noted information. <br />EHD 26-03 <br />Page 1 of 3 SOIL SUITABILITY STUDY CKLST <br />4124112 <br />