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1. SEWAGE: <br /> Distance to Public Sewers: Connection necessary: Yes No ✓ <br /> Does existing septic system comply with San Joaquin County Development Title 4549 ? <br /> Yes _ / No Unknown If no, explain: <br /> Describe septic installation to be installed: <br /> 2. WATER SUPPLY: <br /> Is water supplied by private well: Yes No ✓ Is well proper: Yes No <br /> State deficiency: <br /> Is well system a Public Water system? Yes No Is the permit current? Yes No <br /> Does existing or proposed use make this well Public Water: Yes No Is water/well <br /> sampling current: yes No Additional information or comments: <br /> 3. GARBAGE & REFUSE: <br /> Licensed scavenger pick-up: Yes ✓ No Service Area No.: Other proposed <br /> disposal method: <br /> Potential problem(s): <br /> 4. FLY MOSQUITO OR VECTOR POTENTIAL: <br /> State possible vector potential and necessary control:/ <br /> 5. TOILETIBATH FACILITIES: <br /> Number and locations existing: — 2Z / fir`' Additional <br /> facilities needed: <br /> 6. PREVIOUS OPERATION HISTORY: <br /> 7. GENERAL SANITATION: <br /> i State any problems not previously noted: AIIIAI <br /> 8. POPULATION DENSITY: <br /> 4"Approximate number of people per square mile: �.� ✓ � i�f-cam __ <br /> E14 06 06 Rev 1199 <br />