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NOTE: PULL ALL r-RMITS (Septic, Well, etc.) MAKE COPIES FOR FILE <br /> 1. SEWAGE: 1.04, <br /> Distance to Public Sewers: Connection Necessary ? Yes ❑ No yam. <br /> Does Existing Septic System comply with San Joaquin County Development Title ? Yes No 1; <br /> If no,explain: <br /> Describe Septic System to be installed: <br /> 2. WATER SUPPLY: <br /> Is Water supplied by Private Well ? E] Yes E]yNo Is well properly sealed and constructed ? Yes ❑ 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 No <br /> Is water/well sampling current ? F� Yes F_� No <br /> Additional information or comments: - <br /> 3. GARBAGE& REFUSE: <br /> Licensed scavenger pick-up? ❑ Yes E;�No Service Area No. <br /> Other proposed disposal method: <br /> Potential Problem(s): <br /> a. FLY, MOSOUITO OR VECTOR CONTROL: <br /> Describe potential Vector Control issues: A)Z <br /> 5. TOILET/BATH FACILITIES: <br /> Number and Location(s)of existing facilities: '16114 <br /> Additional facilities required: <br /> 6. PREVIOUS OPERATION HISTORY: <br /> 7. GENERAL SANITATION: <br /> List any problem(s)not previously noted NA <br /> S. POPULATION DENSITY: <br /> Approximate number of people per square mile: <br /> Ell 06 06 Report 07201 Page 2 June 21,2004 <br />