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NOTE: PULL ALI NOW sRMITS (Septic, Well, etc.) MAKE - ')PIES FOR FILE <br /> I. SEWAGE: `-001 <br /> Distance to Public Sewers: Connection Necessary? ❑ Yes No <br /> Does Existing Septic System comply with San Joaquin County Development Title? Yes ❑ No F—] Unknown <br /> If no,explain: <br /> Describe Septic System to be installed: <br /> 2• WATER SUPPLY: <br /> Is Water supplied by Private Well 7 ❑ Yes No Is well properly sealed and constructed ? ❑ Yes 0 No <br /> Describe deficiency, if any: <br /> Is well system a Public Water system ?\;F—] Yes No Is Public Water System Permit current? Yes ❑ No <br /> Does existing or proposed use make this a Public Water System ? ❑ Yes F—] No <br /> Is water/well sampling current ? ❑ Yes F—] No <br /> Additional information or comments: ni <br /> 3. GARBAGE & REFUSE: <br /> Licensed scavenger pick-up? ., Yes F—] No Service Area No. <br /> Other proposed disposal method: <br /> Potential Problem(s): <br /> 4. FLY MOSQUITO OR VECTOR CONTROL: <br /> Describe potential Vector Control issues: <br /> _. <br /> 5. TOILET 1 BATH FACILITIES: <br /> Number and Location(s)of existing facilities: .`._."4.. <br /> Additional facilities required: <br /> 6. PREVIOUS OPERATION HISTORY: <br /> ............. <br /> 7. GENERAL SANITATION: <br /> List any problem(s) not previously noted <br /> r <br /> S. POPULATION DENSITY: <br /> Approximate number of people per square mile: " <br /> Eli 06 06 Deport 97201 Page 2 June 2l,2004 <br />