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NOTE: PULL ALL :RMITS (Septic, Well, etc.) MAKE PIES FOR FILE z <br /> I. SEWAGE: f <br /> Distance to Public Sewers: Connection Necessary? Yes No <br /> Does Existing Septic System comply with San Joaquin County Development Title? Yes No Unknown <br /> I <br /> i If no,explain: <br />' Describe Septic System to be installed: <br /> i <br /> 2. WATER SUPPLY: <br /> Is Water supplied by Private Well? ❑ Yes ❑ No Is well properly sealed and constructed ? Yes No <br /> Describe deficiency,if any: <br /> Is well system a Public Water system? ❑ Yes ❑ No Is Public Water System Permit current? Yes No <br /> Does existing or proposed use make this a Public Water System? ❑ Yes No <br /> Is water/well sampling current? F—] Yes No <br /> Additional information or comments: <br /> 3. GARBAGE&REFUSE: <br /> Licensed scavenger pick-up? ❑ Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential Problem(s): <br /> 4. FLY MOS UITO OR VECTOR CONTROL: <br /> Describe potential Vector Control issues: <br /> 5. TOILET/BATH FACILITIES: <br /> Number and Location(s)of existing facilities: <br /> Additional facilities required: <br /> 6. PREVIOUS OPERATION HISTORY: <br /> 7. GENERAL SANITATION: <br /> List any problem(s)not previously noted <br /> 8. POPULATION DENSITY: <br /> Approximate number of people per square mile: <br /> 6H 06 06 Report#7201 Page 2 June 21,2004 <br /> E <br />