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NOTE: PULL ALL ARMITS (Septic, Well, etc.) MAKL_.,OPIES FOR FILE <br /> 1. SEWAGE: <br /> Distance to Public Sewers: /-/,Z l Connection Necessary ? Q Yes E] No <br /> Does Existing Septic System comply with San Joaquin County Development Title? Yes No Unknown <br /> If no,explain: <br /> Describe Septic System to be installed: <br /> 2. WATER SUPPLY: <br /> Is Water supplied by Private Well? F-1 Yes F-2 No Is well properly sealed and constructed ? Yes No <br /> Describe deficiency,if any: <br /> Is well system a Public Water system? F-1 Yes F-1 No Is Public Water System Permit current? Yes No <br /> Does existing or proposed use make this a Public Water System ? F-1 Yes No <br /> Is water/well sampling current? F-] Yes F-1 No <br /> Additional information or comments: <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 /> 5. TOILET/BATH FACILITIES: <br /> Number and Location(s)of existing facilities: <br /> Additional facilities required: �Y <br /> 6. PREVIOUS OPERATION HISTORY: <br /> 7. GENERAL SANITATION: <br /> List any problem(s)not previously noted X/A <br /> 8. POPULATION DENSITY: <br /> Approximate number of people per square mile: !tom-�IIIS/7S/ .�;i /�ffi <br /> EH 06 06 Repon#7201 Page 2 June 21.2004 <br />