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1 <br /> NOTE: PULL ALL %.wtMITS (Septic, Well, etc.) MAKE MES FOR FILL <br /> 1. SEWAGE: <br /> Distance to Public Sewers: Connection Necessary? ❑ Yes No l <br /> Does Existing Septic System comply with San Joaquin County Development Title? ®,(Yes No U Unknown <br /> If no,explain: <br /> Describe Septic System to be installed: <br /> 2. WATER SUPPLY: <br /> Is Water supplied by Private Well ? ❑ Yes 3 No Is well properly sealed and constructed ? [:] Yes No <br /> Describe deficiency, if any: <br /> Is well system a Public Water system ? 7 Yes F-1 No Is Public Water System Permit current? ❑ Yes No <br /> Does existing or proposed use make this a Public Water System ? r-1 Yes No <br /> Is water/well sampling current? ❑ Yes F-1 No <br /> Additional information or comments: <br /> 3. GARBAGE&REFUSE: <br /> Licensed scavenger pick-up? F-1 Yes F-1 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: <br /> b. 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 /> iH 06 06 Report 47201 April 27,2007 <br />